LOS ALAMOS FEDERATION OF SCHOOL EMPLOYEES MEMBERSHIP AND POLITICAL CONTRIBUTION FORM 2010 President: Ellen MillsVice-Presidents: Ryan Ross Mary CarterTreasurer: Virginia Kachelmeier - LAHS (Classified) - 663-2633Secretary: Therese MuellerMembership: Karyl Ann ArmbrusterMEMBER INFORMATION (For new members and members returning from leave. )Name ______________________________________________Complete Address ________________________________________________________Phone Number _______________ Job Assignment __________________ Site ______________ Registered to vote Yes NoHome e-mail ___________________DUES ARE BASED ON SALARY _____ Payroll Deduction _____ Check ( Make out to LAFSE)Annual Earnings 24 pay periods Annual Dues $37,000 and above $ 18.08 $434.00$12.000 - $36,999 $ 8.67 $234.00$7,000 - $11,999 $ 4.82 $115.00under $6,999 $ 3.55 $ 85.00 The undersigned employee hereby agrees to pay in cash or through employer payroll deduction the annual dues as established by my local in compliance with the local’s constitutional provisions. Deductions will continue unless revoked in writing by me to my local and, if applicable to my employer’s payroll office no later than 30 days prior to the effective date of revocation. Dues paid to the AFT may not be deducted for Federal Income Tax purposes, however, under limited circumstances dues may qualify as a business expense.Signature ______________________________ Date________________ Voluntary Political Action Donations to COPE Deductions__$ 1 .00 per check $ ___ per check $ ________ per year check to LAFSE I hereby further agree to pay through payroll deduction the amount per year to the Committee on Political Education (COPE). This authorization is signed freely and voluntarily and not out of any fear of reprisal and I will not be favored or disadvantaged because I exercise this right. I understand this money will be used to make political contributions by AFT/COPE. This voluntary authorization maybe revoked at any time by notifying LAFSE in writing of the desire to do so. Contributions or gifts to COPE are not deductible as charitable contributions for federal income tax purposes. Signature ______________________________ Date ________________ FOR YOUR RECORDS (Returned to you through interoffice mail) Date entered ______________ Forwarded to payroll (For payroll deductions)________ Entered by ________________________
