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____________________________________________________________
Last Name First Name (and initial)
____________________________________________________________
Home Address Home Phone #
No. of Days worked: ______________ Emp. # __________________
Name of Work Site:__________________________________________
Work Loc# ________________________
I hereby authorize APS to deduct from
the compensation due me one (1) deduction fromeach
of the 24 paychecks representingASCA dues in the amount certified to
APS Board, in writing, by ASCA and
remit same to ASCA. Payroll deductions
will continue unless revoked in writing
by me to ASCA and APS Payroll
offices not later than 30 days prior
to the effective date ofrevocation.
The APS Board assumes no reponsibility
in connection with this authorized
deduction except to act as remitting
agent in forwarding the amount
deducted to ASCA.
____________________________________________________________
Signature Emp. Authorizing Deducation Date:
The ASCA Committee on Political Action collects
voluntary contributions for distribution to
federal, state and local political candidates
who support ASCA's legislative goals.
Membership in good standing with ASCA is not dependent
upon your decision to contribute or not
contribute to ASCA COPE.
____________________________________________________________
Signature of Emp. Authorizing COPE Deduction Date:
Dues paid to ASCA may not be deductible for
Federal Income Tax purposes; however, under
limited circumstances, dues may quality as a
business expense. Contributions for COPE or other
purposes to ASCA are not deductible as
charitable contributions for Federal
Income Tax purposes.
PLEASE PRINT OUT THIS PAGE, FILL IT OUT AND SEND
BACK TO ASCA C/O ATF IN INTERSCHOOL MAIL.
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