Ssa Form 1187 - Request For Payroll Deductions For Labor Organization Dues
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1REQUEST FOR PAYROLL DEDUCTIONS FOR LABOR ORGANIZATION DUES
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2010 SSA Form 1187 rev.
Section 5525 of title 5 United States Code (Allotments and Assignments of Pay) permits
5) an organization which is a designated collection agent of a particular labor organization; and 6)
Federal agencies to collect this information. This completed form is used to request that labor
other Federal agencies for management, statistical and other official functions (without your
organization dues be deducted from your pay and to notify your labor organization of the
personal identification).
deduction. Completing this form is voluntary, but it may not be processed if all requested
Executive Order 9397 allows Federal agencies to use the social security number (SSN) as an
information is not provided.
individual identifier to avoid confusion caused by employees with the same or similar names.
This record may be disclosed outside your agency to: 1) the Department of the Treasury to
Supplying your SSN is voluntary, but failure to provide it, when it is used as the employee
make proper financial adjustments; 2) a Congressional office if you make an inquiry to that office
identification number, may mean that payroll deductions cannot be processed.
related to this record; 3) a court or an appropriate Government agency if the Government is party
Your agency shall provide an additional statement if it uses the information furnished on this
to a legal suit; 4) an appropriate law enforcement agency if we become aware of a legal violation;
form for purposes other than those mentioned above.
Please print in BLOCK UPPERCASE LETTERING using black ink.
1. LAST NAME
FIRST
M.I.
2. HOME ADDRESS
APT. OR SUITE NO.
CITY
STATE
ZIP + FOUR
3. EMPLOYEE SSN
4. DATE OF BIRTH- MM/DD/YY
5. HOME PHONE NUMBER:
)
)
6. NAME OF AGENCY
SOCIAL SECURITY ADMIN
7. OFFICE PHONE NUMBER AND EXT.
)
)
EMAIL :
EXT
.
ENTER YOUR EMAIL TO RECIEVE THE FREE AFGE ACTION NEWS
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 that
full pay period of each month, the amount certified below as the regular dues of the (Name of Labor
Standard Form 1188, Cancellation of Payroll Deductions for Labor Organization Dues, is available
Organization and Local #):
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
L
cancellation will not be effective, however, until the first full pay period which begins on or after the
AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES
next established cancellation date of the calendar year after the cancellation is received in the
and to remit such amount to that labor organization in accordance with its arrangements with my
payroll office.
employing agency. I further authorize any change in the amount to be deducted which is certified by
Contributions or gifts (including dues) to the labor organization shown at the left are not tax
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 provisions
I understand that this authorization, if for a biweekly deduction, will become effective the pay
of the Internal Revenue Code.
GENDER (OPT.)
M
F
DATE - MM/DD/YY
SIGNATURE OF EMPLOYEE
Please “X” the
11/18/10
appropriate box.
Click to PRINT - Sign and give to your Local Rep!
YES
NO
FOR COMPLETION BY AGENCY ONLY—The above named employee and labor organization meet the requirements for dues
return this form to the labor organization.)
withholding. (Mark the appropriate box. If "YES" send this form to payroll. If "NO"
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 - MM/DD/YY
COUNCIL #
220
C
SSA REBATE REQUEST FORM*
RECRUITER LAST NAME:
FIRST
M.I.
RECRUITER SSN:
Email address: ____________________________________ Home phone: ____________________________
Current address: Street: __________________________________________________City: ___________________________________ State: ________Zip:_____________
_
I HEREBY CERTIFY THAT I HAVE RECEIVED A REBATE FROM LOCAL________________ IN THE AMOUNT OF $100
11/18/10
NAME________________________________________________SIGNATURE___________________________________________DATE______________
AFL-CIO
CLC
(*
In compliance with IRS regulations, any recruiter receiving over $600 a year will receive a 1099 tax form.)
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