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Automatic Dues Deduction

Name *

Date of Birth *

Retirement Date *

Email *

County Association *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

I request voluntary withholding of annual membership dues in the Kentucky Retired Teachers Association from my November annuity payment from the Teacher Retirement System of KY. I also authorize TRS to share contact and member identification information with KRTA. This authorization will remain in effect until I choose to terminate by written notice to the Teacher Retirement System of KY prior to October 15 of any year.

Signature (Please Type Your Full Name) *

Date / Time *

I agree that by signing with an electronic signature that is the legal equivalent of my hand written signature.

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