Join the Faculty Association at
I wish to join the UCSF FA. I agree to pay the following dues (check
one) by payroll deduction and to sign Form U669 below or by personal check.
(FA dues are tax deductible: either on Schedule A of your income tax to
the extent that they and other profession-related and income-producing expenses
exceed 2% of your adjusted gross income; or in some instances on Schedule
C without the 2% limitation. Please check with your tax consultant.)
$8.00 per/mo for Assist.
Profs and Acting Profs of Law
per /mo for Associate Professors
$14.00 per/ mo for
Mail Completed Forms to:
UCSF Faculty Association
915 Cole Street #373
San Francisco, CA 94117
My complete mailing address for the membership list is:
UCSF Campus Box Number
Employee Organization Membership Payroll Deduction Authorization UPAY 669
Department Employed at UC
Title at UC
Organization name: Faculty Association at UCSC CampusUCSC
DateAction on this Form to
Become Effective on the Pay Period
Initiation Fees 0
General Assessment 0
I authorize the Regents of the University of California to withhold monthly
or cease withholding from my earnings as an employee, membership dues, initiation
fees, and general assessment as indicated above.
I understand and agree to the arrangement whereby one total monthly deduction
will be made by the University based upon the current rate of dues, initiation
fees, and general assessments.
I also understand that changes in the rate of dues, initiation fees and
general assessments may be made after notice to that effect is given to
the University by the organization to which such authorized deductions are
assigned and hereby expressly agree that pursuant to such notice the University
may withhold from my earnings amounts either greater than or less than those
shown above without obligation to inform me before doing so or to seek additional
authorization from me for such withholdings.
The University will remit the amount deducted to the official designated
by the organization. This authorization shall remain in effect until revoked
by me allowing up to 30 days time to change the payroll records in order
to make effective this assignment or revocation thereof or until another
employee organization becomes my exclusive representative.
It is understood that this authorization shall become void in the event
the employee organization's eligibility for payroll deduction terminates
for any reason. Upon termination of my employment with the University, this
authorization will no longer be in effect. This authorization does not include
dues, initiation fees and general assessments to cover any time prior to
the payroll period in which the initial deduction is made. Payroll deductions
including those legally required and those authorized by an employee are
assigned priorities. In the event there are insufficient earnings to cover
all required and authorized deductions, it is understood that deductions
will be taken in the order assigned by the University and no adjustment
will be made in a subsequent pay period for membership dues, initiation
fees and general assessments.
For University Use Only
Employee ID No________