SDRS Form E-1 -- Rev. 01/19

Member information (Click here for directions and conditions.)

I will be employed by my employer full-time Yes No

I am currently drawing an SDRS benefit Yes No

Social Security Number *Required  *Invalid SSN.

Last Name *Required  Invalid Last Name.

First *Required  Invalid First Name.

MI Invalid Middle Initial.

Maiden Invalid Maiden Name.

Street Address or PO Box *Required  Invalid Address.

City *Required  Invalid City.

State *Required  Invalid State.

Zip *Required  Invalid Zip.

Date of Birth (MM-DD-YYYY) *Required  Invalid DOB

Sex MaleFemale

Marital Status SingleMarried

Phone Numbers (Numbers only) Primary Invalid Primary Phone. Secondary Invalid Secondary Phone.

Email Addresses Primary Invalid Primary Email. Secondary Invalid Secondary Email.

In providing your email address you are granting SDRS permission to include your email address on the SDRS email list. You may unsubscribe from this list at any time by contacting SDRS.

Spouse information (Click here for directions and conditions.)

Social Security Number *Invalid SSN.

Last Name Invalid Last Name.

First Invalid First Name.

MI Invalid Middle Initial.

Maiden Invalid Maiden Name.

Date of Birth (MM-DD-YYYY) Invalid Spouse DOB

Sex MaleFemale

Date of Marriage Invalid Marriage Date

Naming your beneficiary

To name primary and contingent beneficiaries, you must complete SDRS Form E-5 "Beneficiary Designation" and file it with the SDRS office. Additionally, if you name minor children as beneficiaries, you may wish to appoint a custodian and successor custodian using SDRS Form E-5A "Transfer to Minor Form". These forms can be obtained from your employer, the SDRS website - sdrs.sd.gov, or the SDRS office.

Optional spouse coverage (Click here for directions and conditions.)

Effective July 1, 2010, this coverage is closed to new enrollments. Eligibility to continue coverage is limited to members who elected coverage prior to July 1, 2010, and are currently covered by this optional protection. If an employee is currently participating in the optional spouse coverage and is changing employment without a break in SDRS credited service, the employee may elect to continue the optional spouse coverage by indicating continuation of coverage below: Member elects to continue Optional Spouse Coverage during new employment

Member release of information

It is my understanding that SDRS and my employer will exchange personnel and other records and information regarding my benefits as necessary. No information may otherwise be released without authorization of law or my written authorization.

Employer information (To be completed and signed by an authorized agent.)

Employer Number *Required  Invalid. Numbers only.

Employer Name

Employer Telephone *Required  Invalid Phone.

Title of Member Position *Required  Invalid.

Hire Date: (MM-DD-YYYY) *Required  Invalid Hire Date

Employment Type Full-Time Part-Time

Member Participation Began (MM-DD-YYYY) *Required  Invalid Date

Classification of Employee Class AClass B Public SafetyClass B Judicial

School and Regent Employees ClassifiedTeacher/Administrator

If member has elected to continue optional spouse coverage I have notified our payroll unit to begin deducting the voluntary additional contributions beginning in: (MM-DD-YYYY) Invalid Date

Authorized Agent's Name (Typed) *Required  Invalid.