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.