Membership and Authorization for Dues Deductions

I receive my pension from: *

Minnesota State Retirement System (MSRS)

MN Public Employee Retirement Association (PERA)

SS# xxx-xx- (Last 4 Digits Only) * (Required by MSRS and PERA for verification and no other purpose.)

First Name *

Last Name *

Address *

Address 1 *

Address 2

City *

State *

ZIP code *

Authorization

I, the undersigned, hereby join Minnesota Chapter 5, AFSCME, and designate said chapter as my duly chosen and authorized representative to promote and protect my economic welfare to the extent authorized by law. I hereby request and authorize the Public Employee Retirement Systems of Minnesota to deduct from my retirement allowance the amount certified by the Retiree Chapter as the current rate of dues. Notice: In order to comply with Internal Revenue Service rulings, be advised that your membership dues are not deductible for federal income tax purposes.

E-Mail Address

Home Phone

Cell Phone † † By providing your cell phone number you consent to receive calls (including recorded or autodialed calls, or texts) at that number from AFSCME and its affiliated labor, political and charitable organizations on any subject matter. Your carrier’s rates may apply. You may modify your preferences at: https://www.afscme.org/tcpa

Signature

AFSCME Retirees United - Chapter 5

Membership and Authorization for Dues Deductions