Request for Establishment/Change/Cancellation of Voluntary Deduction to the PASS Political Action Committee (PAC)

Prefix

Mr.

Mrs.

Ms.

First Name*

Middle name or Inital

Last Name*

Last four(4) of SSN*

Phone/Email/Work

Home Phone

Cell Phone

Email (do not provide .gov or .mil address)*

Facility/Work Location

Deduction/Action

Action Requested:

Establish Voluntary Deduction
Change Amount Deducted
Cancel Voluntary Deduction

Acknowledge:

I hereby request that a voluntary deduction be established, changed or cancelled as designated above. I understand that if the action requested is an establishment of a voluntary deduction or a change in the amount currently being deducted, that I am authorizing the amount designated above to be deducted each pay period from my biweekly pay and to be forwarded to the PASS PAC.

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