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FORM
1187-R |
PLEASE PRINT, COMPLETE AND MAIL TO
NATIONAL OFFICE (listed below)
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REQUEST FOR AUTHORIZATION
FOR VOLUNTARY ALLOTMENT
OF COMPENSATION FOR PAYMENT OF ORGANIZATION DUES |
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SOCIAL SECURITY NUMBER |
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CSA/CSF |
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CIVIL
SERVICE ANNUITY NUMBER |
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NAME OF RETIRED EMPLOYEE
(LAST/FIRST/MIDDLE)
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HOME ADDRESS STREET
AND NUMBER CITY
STATE
ZIPCODE
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| DATE OF BIRTH MONTH/DAY/YEAR |
HOME TELEPHONE
(___) ______________ |
SEX
F ( ) M ( ) |
Chapter Membership with: |
SPOUSES FIRST NAME: |
SPONSORED BY: |
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SECTION A - AUTHORIZATION
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The United States Office of
Personnel Management is authorized to make an appropriate deduction from my
annuity payments, not to exceed the amount certified by the NATIONAL
ASSOCIATION of POSTMASTERS as the amount of dues for which I am obligated,
and to pay the deducted sum to the NATIONAL ASSOCIATION of POSTMASTERS.
This authorization shall also apply to any and all dues changes certified by
the NATIONAL ASSOCIATION of POSTMASTERS.
This authorization shall be valid until the NATIONAL ASSOCIATION of
POSTMASTERS receives and processes my written notice of cancellation in
accordance with its agreement with the United States of Personnel
Management. Any disputes regarding this allotment authorization shall be a
matter between the NATIONAL ASSOCIATION of POSTMASTERS and myself and I hold
the United States Office of Personnel Management harmless for any erroneous
deductions made pursuant to this authorization.
I also authorize the United States Office of Personnel Management to
disclose any information necessary to execute this request. |
SIGNATURE OF CIVIL SERVICE ANNUITANT
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DATE
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SECTION B - FOR USE BY EMPLOYEE
ORGANIZATION
NAPUS
8 HERBERT STREET
ALEXANDRIA VA 22305-2600
(703) 683-9027
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I hereby certify that the
retired dues of this organization for the above named member are currently
established at
$ 30.00 per year. The amount of the monthly dues withholding
for this member is $ 2.50 .
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SIGNATURE
AND TITLE OF AUTHORIZED OFFICIAL
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| 1187-R 3/93 |
2410161 |
Please direct any inquires to NAPUS at
above address
NATIONAL OFFICE COPY |
