California PERS - Deduction Authorization

AUTHORIZATION TO DEDUCT ASSOCIATION DUES FROM RETIREMENT ALLOWANCES

(Last Name)                            (First Name)                             (Middle)                          (Social Security Number)

 
(Address)     (Number and Street)                                            (City)                                 (State and Zip Code)

 
Name of Former Employer:

Name of Association:

RPOAC
As a member of the above association I hereby authorize the California Public Employees' Retirement System to withhold from my retirement allowance, in accordance with the rules of said system, deductions for membership dues until such time as I file in the office of said association a written request for termination of deductions.  I further authorize the association to certify to the California Public Employees' Retirement System the amount of the dues to be deducted, and any subsequent changes in said amount.  I understand that CalPERS cannot process a termination notice received directly from me, and that excess deductions, taken in error, will be refunded to me by the association and not by CalPERS.
Annuitant's signature:                                                                       Date:

 
TO BE COMPLETED BY THE EMPLOYER - Certification and other information required by the carrier.

DOES NOT APPLY
Authorized signature:                                                                        Date: