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CHECK ONE:

5. Address

BENEFICIARY(IES) FOR REFUND OF CONTRIBUTIONS/SURVIVOR
BENEFITS  - I designate the
following

PRIMARY beneficiary(ies) to receive my Retirement Systems
refund of contributions or survivor benefits if eligible.

7. State

ALL SECTIONS MUST BE COMPLETED

2. Name of Beneficiary (ONE PERSON)

8. ZIP+4

Social Security #

Section II-A

1. Name of Beneficiary (ONE PERSON)

3. Name of Beneficiary (ONE PERSON)

Social Security #

Social Security #

Relationship

Relationship

Section IV

Section I

4. Date of Birth

Relationship

PERSONAL INFORMATION

CERTIFICATION AND CONDITIONS

Section III

3. Name of Beneficiary (ONE PERSON)

Social Security #

Social Security #

Social Security #

Relationship

Date of Birth

BENEFICIARY(IES) FOR INCIDENTAL DEATH BENEFIT (You may not
designate contingent beneficiaries for the Incidental Death

Benefit).  I
designate the following beneficiary(ies) to receive my Retirement Systems
Incidental Death Benefit:

1. Name of Beneficiary (ONE PERSON)

Social Security #

Social Security #

2. Name of Beneficiary (ONE PERSON)

3. Name of Beneficiary (ONE PERSON)

Social Security #

Use for designation of active member beneficiaries and
contingent beneficiaries. You may wish to consult with an attorney/estate
planner before completing this form.

PAGE ____ OF ____

6. City

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

Form 1102

Revised 7/6/2012

Page 1

Print or type in black ink

ACTIVE MEMBER BENEFICIARY FORM

BENEFICIARY DESIGNATION, CONTINGENT BENEFICIARY FOR

ACTIVE MEMBERS ONLY- RETIREES USE FORM 7201

SC Public Employee Benefit Authority

South Carolina Retirement Systems

P.O. Box 11960, Columbia, SC 29211-1960

MEMBER'S SIGNATURE
______________________________________________  WITNESS
_____________________________________________

STATE OF ___________________________________________________________
COUNTY OF __________________________________________

Acknowledged before
me this date ________________________________  NOTARY NAME
_______________________________________________

My Commission Expires
________________________________
NOTARY SIGNATURE
__________________________________________________

Retirement System (check one)

Section II-B

1. Last Name & Suffix

3. Social Security Number

2. First/Middle Name

Contingent Beneficiaries Have No Rights Unless All Primary
Beneficiaries Have Died - I designate the following CONTINGENT beneficiary(ies) to receive my
Retirement Systems refund of contributions or applicable survivor benefits.  If the
contingent beneficiary designation below is blank all previous contingent
beneficiaries will be revoked and your estate will become your contingent
beneficiary.

Sex

Sex

Sex

Sex

Sex

Sex

Sex

Sex

Sex

IMPORTANT:  Please read
the Certification and Conditions sections of the instructions on the reverse
(Page 2) before signing this form. I hereby certify I have read and understand
the information on the reverse (Page 2), including the certification and
conditions, and I agree to the provisions stated.

New
Enrollee

Change of Beneficiary

SCRS

PORS

GARS

JSRS

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

M

F

Text Field

(Do not print)
(Required only when signed by mark)

(Out of state, requires Seal)

Relationship

Date of Birth

Relationship

Date of Birth

Date of Birth

Date of Birth

Date of Birth

Relationship

Relationship

Relationship

2. Name of Beneficiary (ONE PERSON)

1. Name of Beneficiary (ONE PERSON)

Date of Birth

Date of Birth

Date of Birth

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.