Fillable Printable SF 1187

SF 1187

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 (Name of Labor Organization):

and to remit such amount to that labor organization in accordance with

its arrangements with my employing agency. I further authorize any

change 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

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 your 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.

Privacy Act Statement

REQUEST FOR PAYROLL DEDUCTIONS

FOR LABOR ORGANIZATION DUES

Standard Form 1187

Revised March 1989

U.S. Office of Personnel Management

Section A-For Use By Labor Organization

1. Name of Employee (Print or Type-Last, First, Middle)

4. Home Address (Street Number, City, State and ZIP Code)

2. Employee Identification Number (SSN or Other) 3. Timekeeper Number

5. Name of Agency (Include Bureau, Division, Branch or Other Designation)

Name of Labor Organization (Include Local, Branch, Lodge or Other Appropriate Identification)

Signature and Title of Authorized Official Date (Month, Day, Year)

Date (Month, Day, Year)

Signature of Employee

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

1-Agency Copy 2-Labor Organization Copy 3-Employee Copy

Section B-Authorization By Employee

of my employing agency. I further understand that Standard Form 1188,

Cancellation of Payroll Deductions for Labor Organization Dues, is available

from my employing agency, and that I may cancel this authorization by filing

Standard Form 1188 or other written cancellation request with the payroll office

of my employing agency. Such cancellation 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.

I hereby certify that the regular dues of this organization for the above

named member are currently established at $ _______________per

(biweekly pay period) (calendar month). (Strike out whichever period is

not appropriate, based on arrangement with the employee's agency.)

Section 5525 of 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 the

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 party to a legal suit; 4) an

appropriate law enforcement agency if we become aware of a legal violation;