Dues Deduction Request for NIH Fellows

Dues Deduction Request for NIH Fellows

OMB Number: 0925-0783

Expiration Date: 30 November 2027

Burden Time: 3 minutes

Name*

First Name (Given Name)Middle NameLast Name (Family Name)

NIH Badge Number*

NIH Institute-Center

Agency Point of Contact

Email

example@example.com

Home Address (street, city, state, zip code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Labor Organization Name (Include Local, Region, National)

Section A - For Use by Labor Organization

Labor Organization Name (Include Local, Region, National)

I hereby certify that the regular dues of this organization for the above named member are currently established at 1.1% per stipend payment.

Signature

Date*

(month, day, year)

Section B - Authorization by Fellow

I hereby authorize the above-named agency to deduct from my stipend payment the amount certified above as the regular dues of the above-named labor organization and to remit such amount to that labor organization in accordance with its arrangements with the National Institutes of Health. I further authorize any change in the amount to be deducted which is certified by the labor organization as a uniform change in its dues structure.

I understand that this authorization will become effective the first stipend payment following its receipt. I further understand the Dues Deduction Cancellation Request for NIH Fellows form is available from the National Institutes of Health and I may cancel this authorization by filing this form with the NIH Such cancellation will not be effective, however, until the first full stipend payment which begins on or after the next established cancellation date of the calendar year after the cancellation is received.

Contributions or gifts (including dues) to the labor organization are not tax deductible as charitable contributions. However, they may be tax deductible under other provisions of the Internal Revenue Code.

Signature of Member*

Date*

(month, day, year)

The information requested in this form is authorized to be collected pursuant to Privacy Act of 1974 (5 U.S.C. § 552a Providing the requested information is voluntary, however, declining to provide any or all of the requested information may preclude you from having labor organization dues being deducted from your stipend and notifying the labor organization about the deduction. The principal purpose for which the information will be used is to carry out personnel management responsibilities, including the proper disposition of government information and property. The information you provide will be included in the Privacy Act system of records and will be used and may be disclosed for the purposes and routine uses described and published in the following System of Records Notice (SORN): OPM/GOVT-1, OPM/GOVT-5, 09-90-0020, 09-25-0014, 09-25- 0108, 09-25-0140, 09-25-0158, 09-25-0165.

Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-#### Do not return the completed form to this address.