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Last Name First Name M. Social Security No.
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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