ࡱ>  N:bjbj *ffffffffzzzzLdzf*BBBBfC4w5777777,H!c9f"cffBByfBfB55%q0F=!0E,""qqfcc" ,:   Kishwaukee College Annuitants Association Dues Form Submitted by the Kishwaukee College Chapter State Universities Annuitants Association 21193 Malta Road, Malta, IL 60150 * (815) 825-2086, Ext. 2860 n RETIREE n ACTIVE EMPLOYEE n SPOUSE n ACTIVE EMPLOYEE & SPOUSE n RETIREE & SPOUSE n SURVIVING SPOUSE Automatic Dues Deduction from SURS Monthly Annuitant Payment  FORMCHECKBOX  I hereby authorize the State Universities Retirement System (SURS) to deduct from my monthly annuity/retirement payment ($2.50) the amount as certified by the 鶹ӳwaukee Chapter of the State Universities Annuitants Association (SUAA) as current rate of dues. The deduction is to start on the first day of _____________ (month) and will continue until termination is requested in writing. I also authorize SURS to provide change of address information to the Chapter and SUAA. Signature (required):__________________________________________________________________ Dated: _____________________ Automatic Dues Deduction from 鶹ӳ Employee Payroll Check  FORMCHECKBOX  I hereby authorize 鶹ӳ to deduct from my monthly payroll check ($2.50) the amount as certified by the 鶹ӳ Annuitants Association as the current rate of dues. The deduction is to start on the first day of _________________ (month) and will continue until retirement or termination of employment. (Note: Membership status must be updated upon retirement.) Signature (required):__________________________________________________________________ Dated: ______________________ Single Cash Payment  FORMCHECKBOX  I hereby elect to pay membership dues in a single annual payment of $30.00. Membership will begin upon receipt of this form and a check payable to 鶹ӳ Annuitants Association for $30. I understand that $21 of my single annual payment is for State dues and the remaining portion $9 is for the local 鶹ӳ chapter. Spousal Membership  FORMCHECKBOX  I hereby elect to pay annual membership dues of $21 for my Spouse (insert name) _______________________________ for membership in the 鶹ӳ Annuitants Association and State Universities Annuitants Association. I understand the $21 is for State dues only and entitles my spouse to full membership privileges in the local 鶹ӳ chapter for which dues have been waived/are not being required.  FORMCHECKBOX  I authorize a monthly payment of $1.75 for my spouse to be included with the monthly dues deduction option selected under Option A. or B. ($2.50 + $1.75 = $4.25 per month). Signature (required): __________________________________________________________________ Dated: _______________________  FORMCHECKBOX  I have included a single payment of $21 for my spouse with Option C. ($30 + $21 = $51.00) Name: FORMTEXT       FORMTEXT       FORMTEXT    Only fill out if spouse is joining.LastFirstMiddle InitialAddress: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Email Address: FORMTEXT   TVXjl8 : < Z \ ^ ` b h l " $ p r t ĹϹĹĹĹuuiahCJaJjhCJUaJh]hx5>*䴳x5>*䴳]x5Cx5Cx䴳]a*CJaJh<05CJaJ&jvhh5CJUaJh5CJaJjh5CJUaJhx5>*䴳x5>*䴳:x5Cx5Cx5Cx䴳<0CJaJjhCJUaJ#jhhCJUaJ4H~B*,26X $Ifgdxgdxgdx  & F\$gd<0gd<0 & Fgd<0 GHIWXYZ\"69 5DJKļĮĢĢĢĚČzĢĢĚĢ#jbhhCJUaJh]hx5>*䴳x䴳x5Cx56C<0CJaJh]hxCJaJ#jhhCJUaJhCJaJjhCJUaJh<05>*䴳(?)*+,2ֺᲂymGx5CO5C<05CJaJ#jNhhCJUaJh5CJaJhx5CJaJh]hx5CJaJhCJaJhxCJaJh]hx5CJaJh<0CJaJh]hxCJaJjhCJUaJ#jhhCJUaJ#23=>  $&(2468LNPTVZ,.BDFPxe%jhGhx5CJU\%jhGhx5CJU\hGhxCJ%jhGhx5CJU\%j8hGhx5CJU\*jhGhx5CJU\mHnHu%jhGhx5CJU\hGhx5CJ\jhGhx5CJU\'XZ\d[[[[[ $Ifgdxkd $$Ifl\]F"*  064 lad[[ $Ifgdxkd$$Ifl\]F"*  064 la $Ifgdxukd$$Ifl0]*?#064 la ,Tbd[[[[[[ $Ifgdxkd$$Ifl\]F"*  064 laPRbdxz|444444$4J4L4N4P4t4v4x444444ﺒyyyyyf%j hGhx5CJU\hkEhx5CJ\aJhx5CJ\aJU%j hGhx5CJU\%jvhGhx5CJU\*jhGhx5CJU\mHnHu%jhGhx5CJU\hGhx5CJ\jhGhx5CJU\(>55 $Ifgdxkd$$Iflֈ]F"$* b_ 064 la 4 $Ifgdxukdg $$Ifl0]*?#064 la   (For SURS Dues Deduction Only)(Last 4 Digits Only)Telephone: FORMTEXT      Social Security Number:  FORMTEXT      May we publish your mailing and e-mail addresses in the KCAA newsletter: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Please return completed form to: Donna Keller, Treasurer Kishwaukee College Annuitants Association 21193 Malta Road Malta, IL 60150 Contributions to SUAA are NOT deductible as a charitable contribution for tax purposes, but are deductible as a business expense. 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