Looking for a Payroll Deduction Form Templates? Download it for free!

Section 5525 of title 5 United States Code (Allotments and Assignments of

4) an appropriate law enforcement agency if we become aware of a legal violation; 5) an organization

Pay) permits Federal agencies to collect this information. This completed form

which is a designated collection agent of a particular labor organization; and 6) other Federal agencies

is used to request that labor organization dues be deducted from your pay

for management, statistical and other official functions (without your personal identification).

and to notify your labor organization of the deduction. Completing this form

Executive Order 9397 allows Federal agencies to use the social security number (SSN) as an individual

is voluntary, but it may not be processed if all requested information is not

identifier to avoid confusion caused by employees with the same or similar names. Supplying your

provided.

SSN is voluntary, but failure to provide it, when it is used as the employee identification number, may

This record may be disclosed outside your agency to: I) the Department of

mean that payroll deductions cannot be processed.

the Treasury to make proper financial adjustments; 2) a Congressional office

Your agency shall provide an additional statement ifit uses the information furnished on this form for

if you make an inquiry to that office related to this record; 3) a court or an

purposes other than those mentioned above.

appropriate Government agency if the Government is party to a legal suit;

PLEASE PRINT IN BLOCK UPPERCASE LETTERING USING BLACK/BLUE INK.

1. Last Name

First

M.I.

2. Home Address

Unit #

City

State

Zip code

3. Employee SSN

4. Date of Birth - MM/DD/YY

5. Home Phone Number

6. Personal Cell Phone Number (preferred)

7. Office Phone Number

Extension

8. Primary Personal Email (Not your government email address)

Opt Out Email

I would like to receive text messages

from AFGE.

I give permission for AFGE to invite

9. Name of Agency

me to robocalls and tele-town halls

via my personal cell phone.

Section A - Authorization by Employee

I hereby authorize the agency named above to deduct from my pay each pay period, or the first

period following its receipt in the payroll office of my employing agency. I further understand

full pay period ofeach month, the amount certified below as the regular dues of the:

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

American Federation of

Form 1188 or other written cancellation request with the payroll office of my employing agency.

Government Employees

Such cancellation will not be effective, however, until the first full pay period which begins on or

Council # (if applicable)

Local #

after the next established cancellation date of the calendar year after the cancellation is received

and to remit such amount to that labor organization in accordance with its arrangements with

in the payroll office.

my employing agency. I further authorize any change in the amount to be deducted which is

Contributions or gifts (including dues) to the labor organization shown at the left are not tax

certified by the below named labor organization as a uniform change in its dues structure.

deductible as charitable contributions. However, they may be tax deductible under other

I understand that this authorization, if for a biweekly deduction, will become effective the pay

provisions of the Internal Revenue Code.

Gender (Optional)

Other

Signature of Employee

Date Signed MM/DD/YY

FOR COMPLETION BY AGENCY ONLY - The above named employee and labor organization meet the requirements for dues withholding.

Yes

(Mark the appropriate box. If ”YES” send this form to payroll. If”NO” return this form to the labor organization.)

Section B - For Use by Labor Organization

Name of Labor Organization (Indicate Local)

AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO, LOCAL

I. D. Code:

I hereby certify that the regular dues of this organization for the above named member are currently established at $

per biweekly pay period.

Signature and Title of Authorized Official

Date signed MM/DD/YY

REBATE REQUEST FORM *

Fax to

Membership Type

Full-time

Part-time

I hereby certify that I have received a rebate from Local

in the amount of

Name

Signature

Date

I hereby certify that I have received recruiter bonus from Local

in the amount of

Recruiter Name

Signature

Date

Recruiter SSN

Local #

Current Address

City

State

Zip

Notes

*IRS Form 1099 or W-2 will be issued based on current income tax laws by the payer.

Request For Payroll Deductions For Labor Organization Dues - American Federation Of Government Employees

Related Articles

Related forms

Related Categories