Retiree Membership Application Form printable pdf download

CSEA Retiree Membership:

•

Eligibility for membership is open to any person who, while actively

•

The monthly deduction of $2.00 will appear under the

“miscellaneous” code on your pension stub.

employed, was a member or an associate member of the Civil Service

Employees Association, Inc. and who has retired from active employ-

•

If you wish to discontinue dues deduction, you must authorize this

ment OR anyone who receives a retirement allowance from the New

revocation in writing, by completing a revocation card. This card may

York State and Local Retirement Systems or the New York Police and

be obtained by contacting CSEA Headquarters. To terminate dues

Fire Retirement Systems.

deduction, the revocation card must be on file with the Retirement

System before the first of the month in which you want the deduction

•

Membership year October 1st through the following September 30th.

to end.

Effective Jan. 1, 2008 dues will be $24.00 a year, paid direct or through

•

monthly deduction from New York State and Local Employees

Membership becomes effective when the membership

Retirement Systems’ pension allowances.

application has been processed and actual payment of dues is

deducted.

•

Member must authorize dues deduction, in writing, by

completing the “Pension Deduction Authorization” form below. Be

•

Questions about retiree membership, dues deduction or requests for

sure to provide all requested information. Retirement

revocation cards should be directed to the CSEA Membership

number is essential and is printed on your pension check.

Department. Do not call the State Retirement System about dues deduction.

•

Receipt of a retirement allowance is required to process

authorization.

CUT HERE

ETIREE

EMBERSHIP

PPLICATION

To the Administrator of Membership Records:

I am hereby applying for membership in the CSEA Retiree Division. I understand that annual membership dues are $24.00 of which $.50 is

appropriated for political action purposes.

This space for CSEA office use only

SIGNATURE: _____________________________

Date: __________________

( P L E A S E P R I N T )

___________________________________________________________________________________________________________________________________________________________

First Name

Last Name

___________________________________________________________________________________________________________________________________________________________

MAILING ADDRESS

number and street

city

state

zip code

_______________________________________________________

__________________________________________________________________________________________

COUNTY

E-MAIL ADDRESS

(

) _______________________

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER:

_______________________________________________________

Area Code

Home Phone Number

Before I retired, I was employed by ___________________________________________ and was (

) a member of CSEA Local __________

(

) not a CSEA member

(

) a member of ____________________

DATE OF RETIREMENT _____________________________________ MALE/FEMALE _______

Dues, contributions or gifts to CSEA are not deductible as charitable contributions for federal income tax purposes. Dues paid to CSEA, however, may be deductible

as ordinary and necessary business expenses.

⇓

• Fold here and mail to CSEA, Inc. •

CSEA, Inc. / Local 1000, AFSCME, AFL-CIO

143 Washington Ave., Box 7125, Capitol Station, Albany, New York 12224

ENSION

EDUCTION

UTHORIZATION

___________________________________________________________________________________________________________________________________________________________

Last Name

( P L E A S E P R I N T )

First Name

M.I.

___________________________________________________________________________________________________________________________________________________________

MAILING ADDRESS

number and street

city

state

zip code

(

) _________________________________________________________

Area Code

Telephone Number

___________________________________________________________________________________________________________________________________________________________

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER

RETIREMENT NUMBER (Required number printed on pension check)

Pursuant to Section 110-c of the Retirement and Social Security Law, I hereby authorize deductions to be made from my monthly allowance from the New York State

and Local Employees Retirement Systems in the amount necessary to cover membership dues on my behalf to CSEA, Local 1000, AFSCME, AFL-CIO. Authorization is

also given to make any changes the Union certifies to the Retirement System as necessary in the amount of such dues. I, the undersigned, do hereby authorize you to

deduct from my monthly allowance the amount of $2.00 for payment of dues, or any amount as may be certified to you by the Union as my dues. I understand that

CSEA, Local 1000, AFSCME, AFL-CIO is my agent and all requests to begin, modify, or revoke deductions must be submitted through the Union. This authorization

shall remain in effect until revoked by me by written notice through the Union or until otherwise revoked pursuant to law.

_________________________________

______________________________________________________________________________

Date

Signature of Pensioner