The period of at least 12 consecutive months during which I did not perform any services for a participating employer was:
12-Month Break-in-Service Exemption Certification
SC Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
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 7218Revised 7/1/2022Sign in blue or black ink
Retired member (printed name)
Retired member (signature)
Social Security number (last 4)
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.
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.
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