Last Name First Name M. Social Security No.
Street Address City State Zip Home Telephone No.
The amount of deduction will be determined by the NYSUT Benefit Trust based on the programs chosen.
To the Employer:
I hereby authorize you to deduct from each of my salary checks the deduction necessary for the purpose of the NYSUT Benefit Trust. I understand that this authorization may be revoked at any time by written notice to you.
Signature of Employee______________________________ Date
NEW YORK STATE UNITED TEACHERS BENEFIT TRUST
800 Troy-Schenectady Road
Latham, NY 12110-2455