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2. Instructions:

   Please complete this form with your most current information. Be sure your answers are legible and list your name as it appears on your Social Security Card and provide a copy of your Driver's License.

   
   

4. Full Name:*
5. Date of Birth: 00/00/0000*
7. Former Name:*
8. Social Security #:*
10. Current Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
18. Email Address
20. RETIREMENT*

    Are you currently or have been a member of the SC Retirement t Systems'

    1. Yes
    2. No
22. INSURANCE

    If "Yes'·. which insurance?

    1. SCRS
    2. PORS
24. PEBA INSURANCE*

    Are you currently covered under the State (PEBA) insurance plans

    1. Yes
    2. No
26. Coverage

    If “yes". are/were you covered as the

    1. Employee
    2. Dependent Child
    3. Spouse
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field