California PERS - Deduction Authorization
|AUTHORIZATION TO DEDUCT ASSOCIATION DUES FROM RETIREMENT ALLOWANCES|
(Last Name) (First Name) (Middle) (Social Security Number)
|(Address) (Number and
|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.|
|TO BE COMPLETED BY THE EMPLOYER -
Certification and other information required by the carrier.
DOES NOT APPLY