WSDOTMF Retiree Deduction Form

Department of Retirement Systems Voluntary Deduction
Name*

First NameLast Name
Social Security Number*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I do not wish to receive Newsletters and updates regarding the Memorial Foundation.
Check the Retirement System/Plan Code*

P1=PERS 1P2=PERS 2P3=PERS 3T1=TRS 1T2=TRS 2T3=TRS 3E2=SERS 2E3=SERS 3L1=LEOFF 1L2=LEOFF 2N2=PSERES 2_____S1=WSP 1S2=WSP 2U1=JUDICIALJ1=JUDGES
Monthly Deduction Amount*
At my own risk, I authorize DRS to regualry deduct a sufficient amount from my retirement allowence to pay the amount required for my organization dues at my request, under this program. I hold DRS harmless for any problems on charges that occur between the organization and myself.

Deductions will continue until the deduction plan is canceled throuth the organiztion office.

I understand that DRS cannot answer questions about my organization.
Signature*

Clear
Choose One Item (Good while supplies last, subject to availability)*

MLXL2XL3XL
Hoody:

CamoGreenOrange
Full Zip Hoody:

Black w/Camo sleeves
1/4 Zip:

Olive w/Camo sleeves
Fleece Vest:

MaleFemale
Puffy Vest:

MaleFemale
Polo:

Dark Green
No-Iron Gray Dress Shirt:

MaleFemale
T-Shirt:

"Learn the Signs"
Cap:

Real TreeGreenOrangeBlackGray/Lime Green
Blanket:

WhiteBlackGrayBuffalo Plaid
Misc.:

Pin (Mem. Foundation and Ribbon)History BookTravel Cup
Notes:
Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: