Standard Form 1187

Revised June 1989

U.S. Office of Personnel Management

REQUEST FOR PAYROLL DEDUCTIONS
FOR LABOR ORGANIZATION DUES

Privacy Act Statement

Section 5525 of the title 5 United States Code (Allotments and Assignments of Pay) permits Federal agencies to collect this information. This completed form is used to request that labor organization dues be deducted from your pay and to notify your labor organization of the deduction. Completing this form is voluntary, but it may not be processed if all requested information is not provided.

This record may be disclosed outside your agency to: 1) the Department of Treasury to make proper financial adjustments; 2) a Congressional office if you make an inquiry to that office related to this record; 3) a court or an appropriate Government agency if the Government is a party to a legal suit; 4) an appropriate law enforcement agency if we become aware of a legal violation; 5) an organization which is a designated

collection agent of a particular labor organization; and 6) other Federal agencies for management, statistical and other official functions (without your personal identification).

Executive order 9397 allows Federal agencies to use the social security number (SSN) as an individual identifier to avoid confusion caused by employees with the same or similar names. Supplying you SSN is voluntary, but failure to provide it, When it is used as the employee identification number, may mean that payroll deductions cannot be processed.

Your agency shall provide an additional statement if it uses the information furnished on this form for purposes other than those mentioned above.

NAME OF EMPLOYEE (Print, Last Name, First, Middle)                                                       IDENTIFICATION NO. (Social Security or Other)

HOME ADDRESS (Street and Number)                                                                   (City and State)                                                       (ZIP Code)

AGENCY (Include Bureau, Division, Branch or other Designation)

Department of Transportation,  Federal Aviation Administration

NAME OF LABOR ORGANIZATION (Indicate local, branch, lodge or other appropriate identification)

National Native American/Alaska Native (NAAN) Coalition for Federal Aviation Employees- NC0000

I hereby certify that the regular dues of this organization for the above named member are currently established at

$     6.00    per bi-weekly pay period.

SIGNATURE AND TITLE OF AUTHORIZING OFFICIAL

Toi Lee, National Treasurer, NAAN

  DATE

I hereby authorize the above named agency to deduct from my pay each pay period, or the first full pay period of each month, the amount certified above as the regular dues of the Federal Managers Association, Chapter # 185, and to remit such amounts to that labor organization in accordance with its arrangements with my employing agency. I further authorize any changes in the amount to be deducted, which is certified by the above named labor organization as a uniform change in its dues structure.  I understand that this authorization, if for a biweekly deduction, will become effective the pay period following its receipt in the payroll office of my employing agency; and that, if for a monthly deducting , it will become effective the first full pay period of the calendar month following its receipt in the payroll office of my employing Agency.

I further understand that revocation forms, Standard Form No. 1188; Revocation of Voluntary Authorization for Allotment of Compensation for Payments of Labor Organization Dues, are available from my employing agency and that I may revoke this authorization at any time by filing such a revocation form or other written revocation request with the payroll office of my employing agency. Such revocation will not be effective however until the first full pay period which begins on or after the next established cancellation date of the calendar year after the cancellation is received in the payroll office.

Contributions or gifts (including dues) to the labor organization shown at left are not tax deductible as charitable contributions. However, they may be tax deductible under other provisions of the Internal Revenue Code.

SIGNATURE OF EMPLOYEE

  DATE

FOR COMPLETION BY AGENCY ONLY - The above named employee and labor organization meet the requirements for dues withholding. (Mark the appropriate box. If “YES”, send this form to payroll. If “NO”, return this form to the labor organization.)

  YES

  NO