Social Security #/Federal ID#**
Social Security #/Federal ID#**
Retiree Last Name & Suffix
Divorce Decree rec. (office use only)
RETIREMENT PAYMENT PLAN ELECTION AND BENEFICIARY DESIGNATION
If designating more than three beneficiaries, complete and attach an additional Form 7201. Beneficiary designations must be a person, an estate, or an artificial entity.
Please read the attached 2 pages of instructions before completing this form.
RETIREE'S SIGNATURE _______________________________________________ DATE ______________________________________________
WITNESS ___________________________________________________________ DATE ______________________________________________
STATE OF ___________________________________________________ COUNTY OF ______________________________________________
Acknowledged before me this date ______________________________ NOTARY NAME _______________________________________________
My commission expires _______________________________ NOTARY SIGNATURE __________________________________________________
Please read the Authorization section of the attached instructions before signing this form IN BLUE INK.
RETIREE INCIDENTAL DEATH PROGRAM
CHECK IF SAME BENEFICIARY(IES) AS IN SECTION II
RETIRED MEMBER CHANGE OF BENEFICIARY FORM
SC Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
SIGNATURE AND NOTARY STATEMENT
I hereby certify I have read and understand the information on the attached instructions, including the authorization, and I agree to the terms stated.
Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
(Required only when signed by mark)
(Certified copy of legal authorization required with signature other than applicant's)
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY. THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.
Phone Number (include area code)
Marriage License rec. (office use only)
** If an "artificial" beneficiary such as a charity or funeral home is designated, a federal ID number must be furnished in the place of the Social Security number.
Select a payment option if you have a change in marital status and wish to have your monthly benefit changed using the beneficiary information below. See explanation of options on the attached instructions. Please attach copy of new beneficiary's birth certificate. If previously requested, an estimated benefit recalculation is also attached.
Form 7201
Revised 11/1/2017
Death Certificate rec. (office use only)
1. Name of Beneficiary or Estate
1. Name of Beneficiary or Estate
* YOUR BENEFICIARY DESIGNATIONS WILL NOT BE REVOKED UNDER SECTION 62-2-507 OF THE SOUTH CAROLINA CODE OF LAWS BY DIVORCE,
ANNULMENT, OR ORDER TERMINATING MARITAL PROPERTY RIGHTS.