AMERICAN FEDERATION OF STATE, COUNTY AND MUNICIPAL EMPLOYEES, AFL-CIO

AUTHORIZATION FOR PAYROLL DEDUCTION

Local #3357 Staff Attorneys Union

By__________________________________________________________________________________________________________
       PLEASE PRINT                     LAST NAME                                     FIRST NAME                              MIDDLE NAME

To______UAW Legal Services Plans_____________________
                               NAME OF EMPLOYER
Effective______upon receipt___I hereby request and authorize you to deduct from my earnings
                              DATE
each ____payroll period________ an amount sufficient to provide for the regular payment of the current rate of
                PAYROLL PERIOD
monthly union dues established by AFSCME Local Union No. 3357, Council No. 66 . The amount shall be certified by Local Union No. 3357, Council No. 66 and any change in such amount shall be so certified. The amount deducted shall be paid to the treasurer of Local Union No. 3357, Council No. 66 AFSCME. This authorization shall remain in effect unless terminated by me during the two week period _______________________to _____________________ of any year.

____________________________________                             __________________________________________
        SOCIAL SECURITY NUMBER                                                                          STREET ADDRESS

___________________________________________                             ___________________________________________________
        EMPLOYEE'S SIGNATURE                                                                         CITY, STATE, ZIP CODE