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FORM 1187-R
Request and Authorization for Voluntary Allotment of Compensation for Payment of Employee Organization Dues.
Please complete and mail to UPMA National Office(address at bottom).
* Denotes Mandatory Fields
SECTION A – All New Members Complete
Social Security Number:
*
I am a (check one):
*
Civil Service Annuitant
FERS
My Civil Service Annuity*/Final** Number is:
*
Date of Birth:
*
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Home Telephone:
Home
Cell
Gender:
Male
Female
None Selected
Chapter:
*
-Select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Name of Retired Employee:
Prefix:
First
*
:
Middle:
Last
*
:
Suffix:
Home Address:
*
City:
*
State:
*
-Select-
Alabama
Alaska
American Samoa
APO/FPO (CONUS)
APO/FPO (EUR)
APO/FPO (PAC)
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
Personal E-Mail Address:
Sponsored By:
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