STATE ORP ACTIVE INCIDENTAL DEATH BENEFIT

BENEFICIARY DESIGNATION

South Carolina Retirement Systems

SC Public Employee Benefit Authority

Attention:  Enrollment

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

Form 1106

Revised 9/16/2015

 

Print or type in black ink

1. Last Name & Suffix

3. Social Security Number

2. First/Middle Name

4. Date of Birth

5. Address

Section I

2. Name of Beneficiary (ONE PERSON)

3. Name of Beneficiary (ONE PERSON)

1. Name of Beneficiary (ONE PERSON)

Social Security #

Social Security #

Social Security #

Sex

Sex

Relationship

Relationship

Relationship

Date of Birth

Date of Birth

Date of Birth

Sex

Please contact Customer Services with any questions at (803)737-6800, (800) 868-9002 (within SC only), or www.retirement.sc.gov. 

PAGE ____ OF ____

4. Name of Trustee(s)

    Name of Trust Beneficiary (ONE PERSON)

Trust ID, if applicable

Address of Trustee(s)

Social Security #

Date of Birth

Relationship

    Name of Trust Beneficiary (ONE PERSON)

Social Security #

Sex

Date of Birth

Relationship

Section II

Section III

IMPORTANT:

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


MEMBER'S SIGNATURE ____________________________________________ WITNESS ________________________________________________
                                                                 (Do not print)                                                                                   (Required only when signed by mark)
                                                                                                                                      
STATE OF ______________________________________________________ COUNTY OF _______________________________________________


ACKNOWLEDGED BEFORE ME THIS DATE____________________________ NOTARY NAME ___________________________________________


MY COMMISSION EXPIRES_____________________________ NOTARY SIGNATURE __________________________________________________
                                                                                                                                                                               (Out of state, requires Seal)

6. City

7. State

8. ZIP+4

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

CHECK ONE:

PERSONAL INFORMATION

                    BENEFICIARY(IES) FOR ACTIVE INCIDENTAL DEATH BENEFIT
I designate the following beneficiary(ies) to receive the State ORP Incidental Death Benefit:

CERTIFICATION AND CONDITIONS

Sex

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.