Page 24 - June2021

[ ] [ ]
I AM A RETIRED MEMBER OF THE FOP, CHICAGO LODGE #7, IN GOOD STANDING, UNDER THE AGE OF 75, AND I RETIRED AS A SWORN MEMBER OF THE CHICAGO POLICE DEPART- MENT BELOW THE RANK OF SERGEANT. MY CURRENT DUES ARE $50 PER YEAR.
I AM A RETIRED MEMBER OF THE FOP, CHICAGO LODGE #7, IN GOOD STANDING, UNDER THE AGE OF 75, AND I RETIRED AS A SWORN MEMBER OF THE CHICAGO POLICE DEPART- MENT HOLDING THE RANK OF SERGEANT OR ABOVE. MY CURRENT DUES ARE
$50 PER YEAR.
FRATERNAL ORDER OF POLICE, CHICAGO LODGE #7 ELECTRONIC WITHDRAWAL AUTHORIZATION
I HEREBY REQUEST AND AUTHORIZE THE RETIREMENT BOARD OF THE POLICEMEN’S ANNUITY AND BENEFIT FUND TO WITHHOLD MY RETIREE DUES FOR FRATERNAL ORDER OF POLICE, CHICAGO LODGE #7 MEMBERSHIP, PAYABLE ONE TIME PER YEAR FROM MY OCTOBER ANNUITY PAYMENT. I FURTHER REQUEST THAT THE WITHHELD AMOUNT BE FORWARDED ELECTRONICALLY TO A BANK ACCOUNT MAINTAINED BY THE FOP.
CHECK ONE:
SS#XXX-XX_ _ _ _ (Last 4 digits only)
THIS AUTHORITY WILL REMAIN IN EFFECT UNTIL I GIVE WRITTEN NOTICE TO CANCEL IT. IT IS FURTHER UNDERSTOOD THAT ANY AND ALL WITHHOLDING PURSUANT TO THIS AUTHORIZATION IS FOR THE FRATERNAL ORDER OF POLICE. I ACKNOWLEDGE THAT IF THE ANNUAL DUES TO
FOP ARE EVER INCREASED, THE INCREASED AMOUNT WILL BE WITHHELD FROM MY FUTURE OCTOBER PAYMENT. IN THAT EVENT, IT SHALL BE THE FOP’S RESPONSIBILITY TO TIMELY NOTIFY THE PABF RETIREMENT BOARD OF ANY INCREASE.
ANNUITANT NAME (PLEASE PRINT) _________________________________________________________ ANNUITANT SIGNATURE____________________________________________________________________ ADDRESS ___________________________________________________________Unit/Apt#:______________ CITY, STATE, ZIP____________________________________________________________________________
HOME PHONE (
)__________________________ CELL PHONE (
PLEASE RETURN TO: Fraternal Order of Police Chicago Lodge #7 1412 W. Washington Blvd. Chicago, IL 60607
)_____________________________