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. 

Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.

OPTION 2

OPTION 2A (Revert to Max)

OPTION 1

Type I:  RETIREE ONLY ANNUITY

              MAXIMUM OPTION

Type III:  100%-50% JOINT RETIREE-SURVIVOR

Type II:  100%-100% JOINT RETIREE-SURVIVOR

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 a copy of new beneficiary's birth certificate. If previously requested, an estimated benefit recalculation is also attached.                                                                               

Social Security #/Federal ID#**

Social Security #/Federal ID#**

Retiree Last Name & Suffix

RETIREMENT PAYMENT PLAN ELECTION AND BENEFICIARY DESIGNATION

If designating more than three beneficiaries, complete and attach an additional Form 7201G.  Beneficiary designations must be a person, an estate, or an artificial entity.

         .             

2. Name of Beneficiary

QUALIFYING EVENT 

Section II*

Please read the attached page 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.

Section IV

Date of Birth

Date of Birth

Date of Birth

Date of Birth

Date of Birth

Date of Birth

RETIRED MEMBER CHANGE OF BENEFICIARY FORM
SC Public Employee Benefit Authority

General Assembly Retirement System (GARS)
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.

 (Required only when signed by mark) 

  (Certified copy of legal authorization required with signature other than applicant's)  

Section I                                                                                      

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

Zip Code

DATE

Phone Number
(include area code)

Current Beneficiary

First Name/Middle Name

Form 7201G
Revised 11/1/2017 

1. Name of Beneficiary or Estate

Death Benefit Amount

1. Name of Beneficiary or Estate

See Instructions

Retirement Date

GARS

M

F

M

F

M

F

M

F

OPTION 1A (Revert to Max)

Check here if payments are to be paid through a trust and attach a completed Certification of Trust (Form 1113).

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Sex

Sex

Sex

Sex

Sex

Sex

Current Option

Current Beneficiary

Relationship

Current Monthly Benefit

** 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.

* 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.

M

F

M

F