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The period of at least 12 consecutive months during which I did not perform any services for a participating employer was:

  • I hereby certify that, after my date of retirement, there has been a period of at least 12 consecutive months during which I was not engaged to perform services for a participating employer in the state's retirement systems for compensation in any capacity, whether as an employee, independent contractor, leased employee, joint employee, or other classification of worker. 
  • I understand that, if I inaccurately certify that I satisfy the requirements for this exemption, I am responsible for reimbursing the state's retirement systems for any benefits wrongly paid to me as a result of that certification. I further understand that any person who shall knowingly make any false statement or shall falsify or permit to be falsified any record of the retirement systems in any attempt to defraud the systems as a result of such act shall be guilty of a misdemeanor and, upon conviction, may be punished by a fine not exceeding five hundred dollars or imprisonment not exceeding 12 months, or both in the discretion of the court.
  • I understand that PEBA may reject this certification if the documentation or information on file does not support the requirements for this exemption.

12-Month Break-in-Service Exemption Certification

SC Public Employee Benefit Authority

202 Arbor Lake Drive

Columbia, SC 29223

Current/anticipated employer:

Employer 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 PUBLIC EMPLOYEE BENEFIT AUTHORITY.  THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT. 

Form 7218
Revised 7/1/2022
Sign in blue or black ink

Retired member (printed name)

Retired member (signature)

Social Security number (last 4)

Date

RETIRED MEMBER'S EMPLOYMENT INFORMATION

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

For compensation earned during the 2022-2023 fiscal year, the $10,000 earnings limitation does not apply if a member of the South Carolina Retirement System or Police Officers Retirement System has not been engaged to perform services for a participating employer in the state's retirement systems for compensation in any capacity, whether as an employee, independent contractor, leased employee, joint employee, or other classification of worker, for a period of at least 12 consecutive months subsequent to retirement. The exemption provided under this proviso does not apply unless the member first certifies to the system that he satisfies the requirements for the exemption. If a member inaccurately certifies that he satisfies the requirements for the exemption, the member is responsible for reimbursing the system for any benefits wrongly paid to the member. 

AUTHORIZATIONS

CERTIFICATION

Pursuant to Proviso 108.18 of Part IB of H. 5150 of 2022:


Return to work date:

Please complete and email this form to PDept@peba.sc.gov.

BREAK-IN-SERVICE

Begin Date:

End Date: