Name (print):  _________________________________                                       
Social Security #: _____/_____/______
Address: _____________________________________________________

Effective immediately, I hereby authorize the City of Toledo to deduct from my wages $_________ per pay period over and above that which is deducted from Union Dues or any Fair Share Fee.  The purpose of this additional deduction is solely for the purpose of providing funds for the Toledo Firefighters Political Action Committee.  I understand that this is a strictly voluntary contribution and that I have the right to refuse or revoke my authorization without suffering any reprisal.  I understand that this contribution will be used by this committee as they strive to improve the wages, benefits, and working conditions of Firefighters and to provide better service to the public.  This authorization shall remain in effect until revoked or modified by myself, in writing, to the Treasurer of Local #92. 

Signature: _________________________    Date: _____/____/____

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