Request for Payroll Deductions for Labor Organization Dues

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 the
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 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.

The regular dues are $33.50 per pay period.

1187

Name (Last , First, Middle *

Social Security Number or Employee ID (Per SF-50 or Employee Profile) *

Home Address *

Name of Agency (format CA/PPT/??)

Complete agency designation

Personal (non-work) Email Address

Signature *

By typing your name and checking the authorization check box authorizes this form.

Todays Date

Authorization By Employee

I agree

I hereby authorize the above named agency to deduct from my pay each pay period, or the first full pay period of each month, the amount certified above as the regular dues of the (Name of Labor Organization): National Federation of Federal Employees (NFFE) 1998 and to remit such amount to that labor organization in accordance with its arrangements with my employing agency. I further authorize any change in the amount to be deducted which is certified by the above named labor organization as a uniform change in its dues structure. I understand that this authorization, if for a biweekly deduction, will become effective the pay period following its receipt in the payroll office of my employing agency. I further understand 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 Form 1188 or other written cancellation request with the payroll office of my employing agency. Such cancellation will not be effective, however, until the first full pay period which begins on or after the next established cancellation date of the calendar year after the cancellation is received in the payroll office. Contributions or gifts (including dues) to the labor organization shown at left are not tax deductible as charitable contributions. However, they may be tax deductible under other provisions of the Internal Revenue Code.

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