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 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.
Section A--For Use By
Labor Organization
Name of Labor Organization (Indicate Local, Branch, Lodge or Other Appropriate Identification) I hereby certify that the regular dues of this organization for the above named member are currently established at $ __________ per (biweekly pay period) (calendar month). (Strike out whichever period is not appropriate, based on arrangement with the employee's agency.)
Section B-Authorization
By Employee
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 AMERICAN FOREIGN SERVICE ASSOCIATION 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; and that, if for a monthly deduction, it will become effective the first full pay period of the calendar month 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.
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