PAYROLL DEDUCTION AUTHORIZATION

NAME:_________________________________________________________________

            Please Print (Last)                                (First)                           (Middle Initial)

The undersigned hereby authorizes COMMUNITY ACTION AGENCY OF OKLAHOMA CITY, AND OKLAHOMA/CANADIAN COUNTIES, INC. (AGENCY) to deduct from my wages an amount equal to the regular monthly dues, or the equivalent thereof, as certified to the Agency by the Secretary- Treasurer of the AMERICAN FEDERATION OF STATE, COUNTY, AND MUNICIPAL EMPLOYEES LOCAL 2406, AFL-CIO (UNION) and remit the same to the Secretary- Treasurer of the Union or his duly authorized Agent. This authorization may be revoked by me during a ten (10) day period following two hundred fifity-one (251) days after the execution date of the contract.

_____________________                  __________________________________________

Date                                                     Signature of Employee

_____________________                  __________________________________________

Social Security Number                        Home Address

_____________________                  __________________________________________

Date Received by Agency                     City or Town, State, Zip Code

_____________________                  __________________________________________

Effective Date                                       Home Phone and Work Phone

15.2                                  The Union assumes full responsibility for the disposition of the monies so

deducted, once the monies have been turned over to the Union, the Union

agrees to indemnify and save the Agency harmless against any and all claims, suits, or other forms of liability arising out of the deduction of money for Union dues, fees and assessments from the Employee’s pay.

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