Form 8201

Revised 7/10/2012

Please print or type in black or blue ink only.

EMPLOYER REQUEST FOR FORMS

SC Public Employee Benefit Authority

PO Box 11960, Columbia, SC 29211-1960

FAX: (803) 737-7594

ATTENTION: CUSTOMER SERVICES

SOUTH CAROLINA RETIREMENT SYSTEMS

Employer Code Number

Employer Name

Requester Name

Telephone

Current Mailing Address

City

ZIP + 4

Most of these forms are available on our Web site at www.retirement.sc.gov. If you need a paper supply of any of these forms, please indicate the quantities of each form you are requesting in the spaces provided below and fax this form to the number listed above or mail this form to the address listed above. You may also e-mail us a request for forms from www.retirement.sc.gov/contact. Orders are limited to 200 per item.

FORMS

Enrollment/Membership

Retirement Plan Enrollment (Form 1100)

Beneficiary/Trustee Designation (Form 1103)

Election of Non-Membership (Form 1104)

Certification of Trust (Form 1113)

Beneficiary Designation (Form 1102)

State ORP Active Group Life Beneficiary Designation (Form 1106)

Request for Retirement Benefit Estimate (Form 6100)

Customer Claims

Service Retirement Application Packet

(Circle One)

SCRS    PORS

Request for Service Purchase Cost (Form 2101)

Disability Retirement Application Packet

(Circle One)

SCRS    PORS

Refund Request (Form 4101)

Pension Withholding Certificate/Automatic Deposit Authorization (Form 7202)

Other

Our goal is to fill your order within 24 hours of receipt; however, please allow several days for shipping. If you do not receive your order within five business days of your request, please contact Customer Services.

THIS SECTION IS FOR RETIREMENT SYSTEMS? USE ONLY.

Order Fulfillment Information

Date Received

Date Filled

Date Taken to Postal Center

Handled By (Print Name)

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.

If you have questions or need additional information, please contact the South Carolina Retirement Systems? Customer Services Call Center at (800) 868-9002 (toll free within SC only), (803) 737-6800, or www.retirement.sc.gov.