TPEA Member Payroll Deduction Form
To pay your TPEA member dues via payroll deduction, please fill out and sign the form below and we will securely submit it to your HR/Payroll department for processing.
Name
*
First Name
Last Name
Employer (State Agency Name)
*
(For Office Use Only) PIN NO. 17410323699-000 | Monthly Dues: $10 | Type Initials to Acknowledge Dues Amount
*
(For Office Use Only) PIN NO. 17410323699-000 | Monthly Dues: $10
Last 4 Digits of SSN
*
Required by state agencies for identification
Dues Deduction Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please select the first of the month following your form submission. EXAMPLE: If you are submitting this form on June 11, please select July 1.
HOME EMAIL (NO .GOV STATE EMAIL ADDRESSES)
*
Please provide your home email. We cannot send membership info to a state email address.
Your Current Job Title
*
Address (PO Box is acceptable)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile/ Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Can we text you with news and updates?
Yes
No
Referred by (if applicable)
Please put name of referrer or recruiter
AUTHORIZATION FOR PAYROLL DEDUCTION: I understand that I cannot be compelled to be a member of a state employee organization or to pay dues to a state employee organization as a condition of employment with the state. While I am free to join a state employee organization, I understand I may change or cancel this authorization at any time by providing written notice to my employer. I voluntarily authorize a monthly payroll deduction from my salary or wages in the amount shown above or such amount as certified to the Comptroller as the membership dues for TPEA and agree to comply with the comptroller's rules concerning this deduction. I agree that my name, social security number, personal contact information, and the amount of my payroll deduction for membership fees may be provided to TPEA only for the purpose of informing TPEA about the payroll deduction. TPEA membership dues are not deductible as charitable contributions for Federal Income Tax purposes. By signing up for payroll deduction, I agree to pay no less than the monthly amount required for payment of annual membership dues. If membership dues are not paid in full within a twelve-month cycle, TPEA membership may be suspended.
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Submit
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