AFGE FORM 277 FOR AFGE LOCAL 2725

AFGEAUTHORIZATION OR CANCELLATION OF VOLUNTARY DEDUCTION M GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF BUDGET AND FINANCIAL MGT. DISTRICT ACCOUNTING PAY SECTION
FOR PAYMENT OF EMPLOYEE ORGANIZATIONAL DUES
SECTION A - TO BE COMPLETED BY EMPLOYEE
PLEASE PRINT IN BLOCK UPPERCASE LETTERING USING BLACK/BLUE INK.
Last Name
First
MI
Home Address
Apt or Suite No
City
State
Zip Code
Zip Code Four
Personal Cell Phone Number preferred
Office Number
Extension
Please enter a valid phone number.
Home Phone Number
Primary Personal Email Not your government email address
example@example.com
Effective Date

MonthDayYear
Date
I would like to receive text messages

Yes
I give permission for AFGE to invite me to robocalls and tele-town halls via my personal cell phone.

Yes
MJC
Employee SSN (no dashes)
I hereby authorize a deduction from my pay each pay period, to be forwarded to the employee organization named herein:
Cancellation - Enter 0000 Above

Cancellation
New Application - Field Code 096

New Application
NAME OF EMPLOYEE ORGANIZATION
NAME OF EMPLOYEE ORGANIZATION
Signature of Employee

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Date Signed MM/DD/YY

MonthDayYear
Date
SECTION - TO BE COMPLETED BY EMPLOYEE ORGANIZATION
NAME OF EMPLOYEE ORGANIZATION AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES
I hereby certify that the regular dues for the above named member are currently established at: $
$ PER PAY PERIOD
Signature and Title of Authorized Official

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Date Signed MM/DD/YY

MonthDayYear
Date
REBATE RECEIPT
Must have recruiter info to process
Recruiter Last Name
First
MI
Recruiter SSN
Email address
example@example.com
Home Phone
Address

Current Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
*In compliance with DoL regulations, any recruiter receiving over $600 a year will receive a 1099 tax form.
Should be Empty:

FOR PAYMENT OF EMPLOYEE ORGANIZATIONAL DUES

SECTION A - TO BE COMPLETED BY EMPLOYEE

NAME OF EMPLOYEE ORGANIZATION

SECTION - TO BE COMPLETED BY EMPLOYEE ORGANIZATION

NAME OF EMPLOYEE ORGANIZATION AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES

REBATE RECEIPT