REQUEST FOR PAYROLL DEDUCTIONS (Please Print Hard Copy) FOR LABOR ORGANIZATION DUES Complete # 1- 6 Privacy Act Statement Section 5525 of Title 5 United States Code (Allotments and Assignments of Pay) permits Federal Agencies to collect this information. This completed form is used to request that labor organization dues be deducted from your pay and to notify your labor organization of the deduction. Completing this form is voluntary, but it may not be processed if all requested information is not provided. This record may be disclosed outside your agency to: 1) the Department of Treasury to make proper financial adjustments; 2) a Congressional office if you make an inquiry to that office related to this record; 3) a court or an appropriate Government agency if the government is a party to a legal suit; 4) an appropriate law enforcement agency if we become aware of a legal violation; 5) an organization which is a designated collection agent of a particular labor organization; and 6) other Federal agencies for management, statistical and other official functions (without your personal identification). Executive Order 9397 allows Federal agencies to use the social security number (SSN) as an individual identifier to avoid confusion caused by employees with the same or similar names. Supplying your SSN is voluntary, but failure to provide it, when it is used as the employee identification number, may mean that payroll deductions cannot be processed. Your agency shall provide an additional statement if it uses the information furnished on this form for purposes other than those mentioned above. |
1. Name of Employee (Print or Type-Last, First, Middle) |
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2. Employee Identificaiton Number (SSN) |
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3. Home Address (Street Number, City, State and Zip Code |
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4. Name of Agency (Include Service, Division, Branch) |
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Secton A - For Use By Labor Organization. Name of Labor Organization National Federation of Federal Employees Local # 739 I hereby certify that the regular dues of this organization for the above name member are currently established at $12.73.00 per biweekly pay period. |
Signature and Title of AuthorizedOfficial |
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Date (Month, Day, Year) |
Section B - Authorization by Employee I hereby authorize the above named party to deduct from my pay each pay period the amount certified above as the regular dues of the National Federation of Federal Employees, and to remit such amount to that labor organization in accordance with its arrangements with my employing agency. I further authorize any change in the amount to be deducted which is certified by the above named labor organization as a uniform change in its dues structure. I understand that this authorization will become effective the pay period following its receipt in the payroll office my employing agency. I further understand that Standard Form 1188, Cancellation of Payroll Deductions for Labor Organization Dues, is available from my employing agency, and that I may cancel this authorization by filing Standard Form 1188 or other written cancellation request with the payroll office of my employing agency. Such cancellation will not be effective, however, until the first full pay period which begins on or after the next established cancellation date of the calendar year after the cancellation is received in the payroll office. Contributionsor gifts (including dues) to the labor organization shown above are not tax deductable as charitable contributions. However, they may be tax deductable under other provisions of the Internal Revenue Code. |
5. Signature of Employee |
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6. Date (Month, Day, Year) |
FOR COMPLETION BY AGENCY ONLY- The above named employee and labor organization meet the requirements for dues withholding. (Mark the appropriate box. If "YES", send this form to payroll. If "NO", return this form to the labor organiation. |
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Yes No |
