DUES EXONERATION REQUEST

Transport Workers Union of America, AFL-CIO
LOCAL COPY
DUES EXONERATION REQUEST
Fill out both pages (above the signature line for your signature) and then sign and submit them to your local, which will complete the form and rule on your request.
Date

MonthDayYear
Date
Local No
Name
Address
Phone
Format: (000) 000-0000.
I hereby request exoneration from dues amounting to $
for the month(s) of
illness injured or furloughed during the months for which exoneration requested
Dates of absence: from

MonthDayYear
Date
to (or expected return date):

MonthDayYear
Date
Provide any further information regarding reason for exoneration request
Amount of compensation paid or expected in wages and/or compensatory benefits (for each month for which exoneration requested):
Amount of regular monthly income from employment
Signature of member
Title/Occupation
Should be Empty: