Re: Dues of Contra Costa County Employees Association, Local #1 Associate Member (Retired).

I hereby authorize and request you to deduct from my retirement allowance every month, beginning the first such month after your receipt hereof, such sum as is designated to you in writing by the President and Secretary of said Association, and to pay such sum to said Association as my dues; this authorization to be effective on receipt by you until canceled by me in writing.

Name (printed) ________________________________________ Retirement Date ________________

Name (signed) ________________________________________ Date Signed ___________________

Address ___________________________________ City and Zip ______________________________

Telephone (____) ______________________ $2.00 Per Month