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Here you will find the most current versions of the forms used by PEBA Retirement Benefits. To use our forms, you will need to have the Adobe Acrobat Reader installed on your computer.


Number Description
1100 Enrollment Form (All Systems)
1102 Beneficiary Form - Beneficiary Designation, Contingent Beneficiary (All Systems)
1103 Beneficiary/Trustee Designation Form (All Systems)
1104 Election of Non-Membership
1106 State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System)
1107 Employer Certification of Police Officers Retirement System (PORS) Eligibility
1113 Certification of Trust (All Systems)
1117 Change of Address
1162 State Optional Retirement Program (State ORP)
1221 Standard Retirement Quarterly Report (South Carolina Retirement System, Police Officers Retirement System)
1222 Standard Retirement Quarterly Report - Class I Employer (South Carolina Retirement System, Police Officers Retirement System)
1223 Adjustment to Quarterly Payroll Report (South Carolina Retirement System, Police Officers Retirement System)
1224 Supplemental Service Report (South Carolina Retirement System, Police Officers Retirement System)
1226 ACH Debit Authorization
1227 Supplemental Contribution Report (After 07/01/2005)
1340 Fiscal Year Contribution Rates
1341 Due Date Calendar
2101 Request for Service Purchase Cost (All Systems)
2122 Request for Public/Educational Service Verification
2130 Request for ORP Service Verification (Applies to ORP service in South Carolina only.)
2140 General Assembly Retirement System Special Contributing Member Election
2209 Service Purchase Salary Verification
2390 Service Purchase Payment Options (All Systems)
2391 Service Purchase Federal Address List
3227A Requirements for a Participant to Revoke Election to Participate
3228 Employer Resolution on Tax Deferred Payroll Deductions for Installment Purchase
3229 Installment Service Purchase Remittance
4101 Refund Request (South Carolina Retirement System, Police Officers Retirement System)
4257 Certification of Nonexistent Trust (All Systems)
6100 Request for Retirement Benefit Estimate (All Systems)
6101G General Assembly Retirement System Application for Service Retirement Benefits
6101J Judges and Solicitors' Retirement System Application for Service Retirement Benefits
6101N NGRS Service Retirement Application
6101P Police Officers Retirement System Application for Service Retirement Benefits
6101S South Carolina Retirement System Application for Service Retirement Benefits
6151P Police Officers Retirement System Application for Disability Retirement
6151S South Carolina Retirement System Application for Disability Retirement
6253 Employer's Disability Employment Status Report
6291 Administrative Appeal Disability Report
6302 Retiring Member's Service Application Checklist
6352 Retiring Member's Disability Applications Checklist
6376 TERI Program Reminders
6500 Employer Eligibility Determination Request
6501 Employer Resolution And Application (SCRS)
6501P Employer Resolution And Application (PORS)
6502 Application to Append Coverage for Incidental Death Benefit (SCRS)
6502P Application to Append Coverage for Incidental Death Benefit, Accidental Death Program And/Or Firefighters Coverage (PORS)
6503 Electronic Employer Services (EES) Employer Confidentiality Agreement
6504 Electronic Employer Services (EES) Authorizing Contact Designation/Agreement
6505 Electronic Employer Services (EES) Designated Agent Confidentiality Agreement
7201 Retired Member Change of Beneficiary (South Carolina Retirement System, Police Officers Retirement System)
7201G Retired Member Change of Beneficiary Form (GARS)
7202 Withholding Certificate for Monthly Benefit Payments
7204 Direct Deposit Authorization
7213 Authorized Representative Form
7500 Teacher and Employee Retention Incentive (TERI) Payout Election Form
7700 Deduction Form, Public Safety Officer Insurance Payment Program - EIP Only
7701 Deduction Form, Public Safety Officer Insurance Payment Program - Non-EIP
7800 Deferred Annuity Account (JSRS) Payout Form