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)         (Zip)

                      

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: