CSS2HTML: WEB7201.XDP

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

2. Name of Beneficiary

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.

QUALIFYING EVENT 

Section II 

Please read the attached 2 pages of instructions before completing this form.

2. Name of Beneficiary

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.

Section IV

Relationship  (Check one)

Relationship  (Check one)

Date of Birth

Date of Birth

Date of Birth

RETIREE INCIDENTAL DEATH PROGRAM

CHECK IF SAME BENEFICIARY(IES) AS IN SECTION II        

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Date of Birth

Date of Birth

Date of Birth

Sex

RETIRED MEMBER CHANGE OF BENEFICIARY FORM
SC Public Employee Benefit Authority

South Carolina Retirement Systems
PO Box 11960, Columbia, SC  29211-1960      

Sex

Relationship  (Check one)

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)  

Sex

Sex

Section I                                                                                           

Sex

Social Security #

Social Security #

3. Name of Beneficiary

Social Security #

Social Security #

Social Security Number

System

Mailing Address

City

State

Date of Birth

3. Name of Beneficiary

Section III

Zip Code

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 RETIREMENT SYSTEMS.  THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT. 

DATE

Current Option

Phone Number
(include area code)

Current Beneficiary

Current Beneficiary

First Name/Middle Name

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.

Relationship

Form 7201
Revised 2/3/2017

Death Certificate rec.                                        (office use only)

1. Name of Beneficiary or Estate

Death Benefit Amount

Current Monthly Benefit

1. Name of Beneficiary or Estate

See Instructions

Sex

Retirement Date