Annuitant Deduction Authorization

Illinois Public Employees Retiree Chapter 31
American Federation of State, County & Municipal Employees
615 South Second Street, P.O. Box 2328, Springfield, IL 62705-2328

Illinois State Universities Retirement System (IL SURS)

First Name *

Middle Name

Last Name *

Address *

Address 1 *

Address 2

City *

State *

ZIP code *

Social Security Number (Last 4 digits only) * (Required by the retirement system)

Birth Date *

Month

Day

Year

Surviving Beneficiary

If Surviving Beneficiary of Retiree, Check Here

Retirement Date *

Month

Day

Year

Personal Email Address *

Home Phone *

Cell Phone † † By providing your cell phone number you consent to receive calls (including recorded or autodialed calls, or texts) at that number from AFSCME and its affiliated labor, political and charitable organizations on any subject matter. Your carrier’s rates may apply. You may modify my preferences at: https://www.afscme.org/tcpa.

Authorization

I hereby authorize the State of Illinois or associated agencies to deduct each month the amount certified by the Retiree Chapter as the current rate of dues. This deduction is to be turned over to the Public Employees Retiree Chapter 31, AFSCME.

Signature

AFSCME Retirees Chapter 31 Membership Card

Illinois State Universities Retirement System (IL SURS)

Annuitant Deduction Authorization