____________ ____________ __ ___________________ 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