Illinois State Employees Retirement System (IL SERS)

Annuitant Deduction Authorization

Illinois Public Employees Retiree Chapter 31
American Federation of State, County & Municipal Employees
615 South Second Street, P.O. Box 2328, Springfield, IL 62705-2328

Illinois State Employees Retirement System (IL SERS)

Retiree Name:

First Name

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Social Security Number (Last 4 digits only)

(Required by the retirement system)

Birth Date

Retirement Date

If Surviving Beneficiary of Retiree, Check Here

Beneficiary Name:

First Name

Last Name

Home Phone

Cell Phone †

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Authorization

I hereby authorize the State of Illinois or associated agencies to deduct each month the amount certified by the Retiree Chapter as the current rate of dues. This deduction is to be turned over to the Public Employees Retiree Chapter 31, AFSCME.

Signature

My electronic signature is a binding and valid signature. By signing here I agree to all of the terms and conditions set out in this authorization, which apply to my membership, dues payments and, if applicable, PEOPLE payments.