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DUES DEDUCTION AUTHORIZATION FORM
(dues deduction is only available to SURS Annuitants, not
current MVCC employees)
State Universities Retirement System of Illinois
1901 Fox Drive, Champaign, IL 61820
submitted by
Moraine Valley Community College Annuitants
Association
A Chapter of the State Universities Annuitant
Association
C/O Steven P. Lebre, 303 S. Pine Street, New Lenox, IL
60451
I hereby authorize the State Universities Retirement System (SURS) to deduct each month the amount of $2.1666666 (for a yearly total of $26.00: $21 to SUAA and $5 to MVCCAA) to be credited to the MVC Chapter of the State Universities Annuitant Association at the above address. The deduction is to start for the 1st of the month of _____________ 20___. I also authorize SURS to provide a change of address information to the Chapter.
Name: __________________________________ Spouse:
________________
Last
First
M.I.
Address:
________________________________________________________
Number
Street
Apt. No.
City: _________________________ State ______________ Zip: ___________
Social Security No.: _____-____-______
Telephone: (____) ____ ___________
SURS must have the Social Security number for record
keeping purposes!
Please check the membership classification which
best applies to you:
(___) Retiree (___) Spouse and Annuitant (___) Survivor
Signature: _______________________________ Date: ___________________
Please return this form with your membership application (new or renewal) to Steven P. Lebre, MVCCAA Treasurer, 303 S. Pine St., New Lenox, IL 60451. In brief, membership dues will be deducted from your SURS pension check until you cancel (by notifying the MVCCAA Treasurer, SURS, or SUAA). Thus, it will not be necessary to renew your MVCCAA membership annually. It will now be done automatically until you cancel the dues deduction option.
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