REQUEST FOR ANNUITANT DEDUCTIONS FOR LABOR ORGANIZATION DUES

Standard Form No. 1187A
Revised February 2002
Office of Personnel Management
FPM Chapter 550

REQUEST FOR ANNUITANT 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 annuity 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 annuity deductions cannot be processed,

The Retirement Accounts Division of the Department of State shall provide an additional statement if it uses the information furnished on this form for purposes other than those mentioned above.

1. Name of Annuitant (Print-Last, First, Middle)	2. Social Security Number

4. Home Address (Street Number, City, State and ZIP Code)	5. Name of Former Agency
	6. Phone Number
	7. Email (Optional)

Section A--For Use By Labor Organization

Name of Labor Organization: AMERICAN FOREIGN SERVICE ASSOCIATION

I hereby certify that the regular dues of this organization for the above named member are currently established at $ __________ per calendar month.

Signature and Title of Authorized Official (AFSA)

Date (Month, Day, Year)

Section B-Authorization By Annuitant

I hereby authorize the Retirement Accounts Division of the Department of State to deduct from my annuity 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 the Retirements Account Division of the Department of State. 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 is for a monthly deduction, it will become effective the first full pay period of the calendar month following its receipt in the AMERICAN FOREIGN SERVICE ASSOCIATION. I further understand that I may cancel this authorization by filing a written cancellation request with the Retirement Accounts Division. Such cancellation will not be effective, however, until the first full month of the calendar year after the cancellation is received in the Retirement Accounts Division.

Signature of Annuitant

Date (Month, Day, Year)

For Completion By Agency Only - The above named annuitant and labor organization meet the requirements for dues withholding.
(Mark the appropriate box. If "Yes", send this form to payroll. If "No", return this form to the labor organization.)

YES