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.Format: (000) 000-0000.
Email
example@example.com
Check the Retirement System/Plan Code
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
Choose One Item (Good while supplies last, subject to availability)
Hoody:
Full Zip Hoody:
1/4 Zip:
Fleece Vest:
Puffy Vest:
Polo:
No-Iron Gray Dress Shirt:
T-Shirt:
Cap:
Blanket:
Misc.:
Notes:
Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: