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SC Public Employee Benefit Authority

South Carolina Retirement Systems

P.O. Box 11960, Columbia SC 29211-1960

Withholding Certificate for Monthly Benefit Payments

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Mailing Address

City

State

Zip Code

Social Security Number

Phone Number with Area Code

First Name/Middle Initial

Suffix

Payee Last Name

Check appropriate box: 

Check appropriate system:

Member SSN:

Federal Income Tax Withholding

Complete the following applicable lines:

Check box if you do not want any federal income tax withheld from your monthly annuity payment.

(Do not complete lines 2 or 3.)

1

2

Total number of exemptions and marital status you are claiming for withholding from each monthly annuity payment.  (You may also designate an additional dollar amount on line 3.)

Marital Status:

Additional amount, if any, you want withheld from each monthly annuity payment.

Note: For monthly annuity payments, you cannot enter an amount here without entering the number (including zero) of allowances on line 2.  This amount will be withheld in addition to the amount calculated using the marital status and allowances from line 2 above.

3

$

South Carolina State Income Tax Withholding

Complete the following applicable lines:

Check box if you do not want any South Carolina state income tax withheld from your monthly annuity payment.

(Do not complete lines 5 or 6.)

4

5

Total number of exemptions you are claiming for withholding from each monthly annuity payment.  (You may also designate an additional dollar amount on line 6.)

Additional amount, if any, you want withheld from each monthly annuity payment.

Note: For monthly annuity payments, you cannot enter an amount here without entering the number (including zero) of allowances on line 5.  This amount will be withheld in addition to the amount calculated using the marital status and allowances from line 5 above.

6

$

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.

____________________________

__________________________________________

Payee's Signature

Date

(OR mark with "X" with two witnesses  OR Power of Attorney, if on file with the Retirement Systems)

This form must be signed and dated.  See notes on Page 2.

Form 7202

Revised 7/27/2012

(Enter number of exemptions)

(Enter number of exemptions)