SECTION II                                                            REASON FOR CHANGE

STATE OPTIONAL RETIREMENT PROGRAM (STATE ORP)

NOTICE OF TERMINATION OR CHANGE

SC Public Employee Benefit Authority

Attention: Enrollment

202 Arbor Lake Drive

Columbia, SC 29223

1. Last Name & Suffix 

3. Social Security Number

2. First/Middle Name   

6.  State 

7.  Zip + 4 

4. Address

5. City

9. Current Service Provider

Return completed form to the SC Public Employee Benefit Authority (see address above).
Please contact PEBA's Customer Contact Center with any questions at 803.737.6800, 888.260.9430 or www.peba.sc.gov.

Form 1162

Revised 12/1/2020

Print or type in

black ink

8. Email Address

Date:

New Service Provider:

Effective Date:

 Date:

Employer Code:

Employer Name:

Employee Signature:

Date:

Employer Phone Number:

Authorized Employer Signature:

Employer Email Address:

10. Employee Phone Number

*Service provider changes are only allowed during open enrollment and the effective date of the change will be April 1 of the corresponding year.