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AFSCME PAYROLL DEDUCTION AUTHORIZATION
(Please Print)


Employee Name_____________________________________________________________________Soc. Sec#_________________________
                                           FIRST                                          MIDDLE                                               LAST

Address_____________________________________________________________________________________________________________
                                           STREET                                                                                                        CITY                                          STATE                             ZIPCODE

Work Location________________________________________________________Total Deduction Amt_______________________________

I authorize my employer, the School Board of Polk County, Florida, to deduct the amount indicated and remit same as instructed by AFSCME Local 2227. I understand that the deduction amount may change and consent to such change without the necessity of additional authorization.
Dues Deduction Authorization Cards and Forms: Dues, contributions or gifts to AFSCME are not deductible as charitable contributions for federal income taxes purposes. Dues paid to AFSCME, however, may qualify as business expenses and may be deductible in limited circumstances subject to various restrictions imposed by the Internal Revenue Services.
This authorization will remain in effect until I give my employer written notice to cancel.


Date_________________________________________________Home Phone____________________________________________________

Signature____________________________________________________________________________________________________________

If you would like to join your Local Union. Please print, fill out, and send the card through the courier to: Jackie Kelley WH 5