ࡱ> lqk~y Zbjbj 4l{{n n 8ln%"(L($$$$$$$$W' *%i%Hi%X$$Pfd$%0%*H**&%%%*n  |: DEPARTMENT OF HOMELAND SECURITY Transportation Security Administration VOLUNTARY DEDUCTION / CANCELLATION OF AFGE UNION DUES INSTRUCTIONS: Sections I, II, and IV are to be completed by employee. Section III must be completed by the AFGE Local Representative, and Section V will be completed by the TSA Office of Human Capital (OHC) HRAccess. Please type or print the required information in the spaces below. Human Resources/Payroll Specialist will retain the original and provide a copy to the employee.SECTION I. Employee InformationLast Name:  FORMTEXT      First Name:  FORMTEXT      SSN: (full)  FORMTEXT      Home Address: (Number and Street)  FORMTEXT popkpokp (City) (State)(State)(Zip Code)  FORMTEXT        FORMTEXT       FORMTEXT    FORMTEXT      Contact Number: (  FORMTEXT     )  FORMTEXT     -  FORMTEXT     Airport Code/Office:  FORMTEXT     Personal email address: (optional)  FORMTEXT      SECTION II. Voluntary Deduction Request Labor Organization  American Federation of Government Employees (AFGE) Action Requested: (check only one box)  FORMCHECKBOX  Establish AFGE Dues Deduction  Employees must contribute dues for a minimum of one (1) year.  FORMCHECKBOX  Cancel AFGE Dues Deduction Cancellations must be submitted during the time frame specified in Section IV. SECTION III. Union Representative OnlyAmount to be Deducted Bi-weekly: $  FORMTEXT      ID or Local Number: (if applicable):  FORMTEXT 1040 FORMTEXT       FORMTEXT      Union Representative NameUnion Representative SignatureDateSECTION IV. Employee Acknowledgment I hereby authorize TSA to deduct from my pay each pay period the amount certified above as the regular dues of the AFGE Local, and to remit such amount to AFGE in accordance with its arrangements with TSA. I understand that this authorization will become effective the pay period following its receipt in the TSA Payroll Office. I understand that the AFGE has the right to change the amount to be deducted when certified by AFGE at any given time after my membership begins. I further understand I must resubmit this form to cancel dues deductions for AFGE, and that I may only cancel this dues deduction after my initial one-year anniversary membership date or upon my selection to a position not covered by the bargaining unit. I fully understand that after completing my initial one (1) year of contributions, I can cancel my contributions within two (2) pay periods prior to or two (2) pay periods after my anniversary membership date each year. Cancellations relating to a position change can be submitted upon the effective date of this action. Cancellations will be effective the first full pay period after the form is received in the TSA Payroll Office. Bargaining unit employees who have elected to have dues withheld, who are reassigned from one airport to another, will continue to have dues withheld.  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TSA Payroll Office Use ONLYVoluntary Deduction Code:  FORMTEXT      Collection Code:  FORMTEXT       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); E.O. 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 requested by AFGE for reporting requirements. Supplying your SSN is voluntary, but failure to provide it may result in inability to process your payroll deduction/cancellation request.     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