DEPARTMENT
Transportation
VOLUNTARY
OF HOMELAND SECURITY
Security Administration
DEDUCTION I CANCELLATION
OF AFGE UNION DUES
Date
Date
I understand that
Please
this
that
the
Union Representative
Signature
(City)
) I, (State)
(Zip Code)
I Airport
Code/Office:
INSTRUCTIONS:
Sections
II, and IV are to
be completed
by
or
employee.
Local Code:
Number:
Section
(if applicable):
III must be completed by the AFGE
I First
Name: IliDCollection
AFGE
Local,
and
to
remit
such
amount
to
AFGE
in
accordance
with
its
arrangements
with
TSA.
yroll
Office.
tain
the
original
Local
elected
effective
the
dues
provide
Cancellations
contributions
and
bargaining
deduction
Representative,
to
a
the
copy
have
first
within
relating
to
dues
unit.
after
full
the
two
pay
withheld,
I
my
employee.
to
and
fully
(2)
initial
a
period
position
Section
pay
understand
who
one-year
after
periods
are
V
change
the
will
reassigned
that
prior
anniversary
form
be
can
after
completed
to
is
or
be
received
completing
from
two
submitted
membership
(2)
one
by
in
pay
the
airport
the
upon
my
periods
TSA
TSA
date
initial
to
the
Office
Payroll
another,
or
after
effective
one
upon
of
my
Office.
(1)
will
Human
my
anniversary
date
year
continue
selection
Bargaining
of
Capital
of
this
contributions,
to
membership
to
action.
have
(OHC)
unit
a
position
dues
employees
Cancellations
HRAccess.
withheld.
I
date
can
not
covered
cancel
each
who
will
year.
have
my
by
be
y given
time SECTION
begins.
after
my
I
membership
further
understand
I
must
resubmit
this
form
to
cancel
dues
deductions
for
AFGE,
and
that
I
may
only
this
SECTION
I.
Employee
Information
Cancel
Establish
AFGE
AFGE
Dues
Dues
Deduction
Deduction
-from
Cancellations
- Employees
must
must
be
contribute
submitted
dues
during
for
athe
minimum
time frame
of
one
specified
(1)
Section dues
IV. of the
Action
Requested:
(check
one
box).,
III.
Union
Only
SSN:
(full)pay
Amount
toauthorize
be
Deducted
Bi-weekly:
$Request
Labor
Organization
-Representative
American
Federation
Government
Employees
(AFGE)
SECTION
II.
Voluntary
Deduction
I hereby
TSA
toonly
deduct
my I of
pay
each
period
the
amount
certified
above
as year.
theinregular
Last
Name:
Voluntary
Deduction
Code:
DD
Signature
TSA Payroll Office Processing
Instructions
- Forward
to:
TSA HRAccess Shared Service Center
Metroplace1,
2650 Park Tower Drive, Suite 201
Vienna, VA 22180-7300
PRIVACY ACT STATEMENT:
AUTHORITY:
49 U.S.C. § 114(n); ED. 9397. PRINCIPAL PURPOSE(S):
To request that union dues be
deducted from your pay, or cancel union dues from being deducted from your pay, and notify AFGE accordingly,
ROUTINE USE(S):
Information may be shared with the Department of the Treasury, with employees of AFGE, or for other routine uses listed in the
Transportation Security Administration's system of records notice, DHS/TSA 022 National Finance Center (NFC) Payroll Personnel System.
DISCLOSURE:
Voluntary; failure to furnish the requested information may result in an inability to process your request. Your SSN is
requirements.
Supplying your SSN is voluntary, but failure to provide it may result in inability to process
requested by AFGE for reporting
your payroll deduction/cancellation
request.
TSA Form 1158-1 (9/11) [File:
1100.2.1-b(3)]
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