Fillable Retired Scdps Membership Form (Page 2 of 3) in pdf

Retired Scdps Membership Form Page 2

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Complete Retired Scdps Membership Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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3. 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. PAYROLL DEDUCTION INFORMATION

Thank you for your service! Retired SCDPS Membership dues are $72 per year. Your total dues are

$72 per year. By using Payroll Deduction, each check will automatically be deducted just $6. 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: __________________

Retired Scdps Membership Form Page 2

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