(Required only when signed by mark)

26.  I hereby certify that the employee listed in Section I of this form is eligible for the retirement plan selected.                            

17. Select State ORP Service Provider
                                         

1. Last Name & Suffix

Form 1100
Revised 7/1/2023
Page 1

Print or type in black ink.

Please read the instructions on Page 2 before completing this form.

5. City

7. ZIP+4

8. Gender

9. Date of Birth

SECTION II: EMPLOYER INFORMATION (TO BE COMPLETED BY THE EMPLOYER)

20. Employer Name

21. Please indicate if you are the employee's primary or secondary employer.

25. Employee's Annual Salary

24. Employee's Position Title

23. Date of Membership

10. Telephone Number

18. An employee hired by an eligible employer (school district, higher education, technical college, state department, agency, bureau, commission, and institution) covered under the South Carolina Retirement System (SCRS), or individuals first elected to the S.C. General Assembly in and after November 2012, may elect to participate in either the traditional defined benefit plan, SCRS, or the optional defined contribution plan, State Optional Retirement Program (State ORP). The election to participate in State ORP must be made within 30 calendar days after entry into service (date of hire).

    If I do not make an election within the required time, I will be considered to have elected membership in SCRS.  Participants in the State ORP assume all investment risk. The election to participate in State ORP is irrevocable, except a State ORP participant may make a one-time irrevocable election to join SCRS during any open enrollment period after the first anniversary, but before the fifth annual anniversary of the initial enrollment in State ORP.

    I understand that, unless a designated beneficiary is on file, my estate will be designated as my beneficiary until PEBA and/or my selected State ORP service provider receives from me a properly executed beneficiary form.

    My signature below indicates that my employer has explained the retirement plan options available to me and has provided me with access to information necessary to make an informed choice.  My signature on this document confirms my retirement plan election as indicated in block 16 above.

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

15. Are you now receiving or have you applied to receive a monthly benefit

Did you withdraw your contributions? 

14. Do you currently have a pending refund request?

2. First/ Middle Name

6. State

22. Original Date of Hire with Employer listed
       in Items 19-20

ACTION REQUESTED (Check One):

16. Retirement Plan Election (CHOOSE ONE)             

19. Employer Code

Employee's Signature

Date

Witness

12. Have you ever been a member of PEBA's retirement systems?       

13. If item 12 is "Yes," indicate the name(s) of your former employer:

4. Address

RETIREMENT PLAN ENROLLMENT

S.C. Public Employee Benefit Authority

Retirement Benefits

Attention: Enrollment

202 Arbor Lake Drive

Columbia, SC 29223 

3. Social Security Number

11. Email Address

(attach copy of Social Security card only if changing SSN)

M - Male

F - Female

 from any of PEBA's retirement systems?

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