Retired Scdps & Associate Spouse Membership Form Page 2
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33. BENEFICIARY INFORMATION
‐‐ Accurate Beneficiary Info is required in order to ensure your loved ones get the benefits to which they are entitled ‐‐
Last Name: _________________________ First Name: _________________________ MI: _______
Birthdate: __________________________ Social Security Number: __________________________
Street, City, State, & Zip: _____________________________________________________________
Relationship to You: __________________________________
4. SPOUSE’S INFORMATION (for ASSOCIATE SPOUSE MEMBERSHIP)
Last Name: _________________________ First Name: _________________________ MI: _______
Mr. or Ms./Mrs.: ________ Preferred Email Address: ______________________________________
Birthdate: __________________________ Social Security Number: __________________________
Street: __________________________________________________________________
City: ________________________ State: ____ Zip: ___________ Phone: ____________________
sctroopers.org Username: __________________________________
(Hasn’t signed up yet? Type ‘NA‘)
5. PAYROLL DEDUCTION INFORMATION
Thank you for your service! Retired SCDPS Membership dues are $72 per year. Associate Spouse
Membership dues are $72 per year. Your total dues are $144 per year. By using Payroll Deduction,
each check will automatically be deducted just $12. You can cancel your Payroll Deduction at any
time. We look forward to serving you!
Just type an ‘X’ beside the appropriate statement below:
________ No, I have never authorized the SCTA to make a Payroll Deduction before today
________ Yes, I have previously authorized the SCTA to make a Payroll Deduction before today
Now, just sign your name below AND in the GREEN highlighted area on the next page and we’ll take
care of the rest!
___________________________________
_____________________
Your Signature
Today’s Date
For Office Use Only
Date Received: __________________ Date Entered: __________________ Cert. Issued: __________________
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