PAYROLL DEDUCTION FORM

P.S.E.C.-PAC

Name:___________________________________________________________

Home Address:_______________________________________________Zip:___________

Home Phone:_________________ Home E-mail:___________________________________

TYPE OF ACTION:                 CONTRIBUTION:        AGENCY:________________

___Initial Authorization                         ____$ 1.00 per pay period          EMPLOYEE #___________________

___Change in Deduction                       ____$1.50 per pay period          WORK  PHONE:___________________

___Cancellation                                      ____$2.00 per pay period          WORK LOCATION:_________________
                                                                       
                                                                   ____$_____(other) specify 
                                                                                         In $.50 increments: Minimum contribution-$1.00 per pay period

I hereby authorize the State Comptroller to deduct from my salary the sum noted above and to forward that amount to the P.S.E.C.-PAC.   This authorization is signed freely and voluntarily and not out of any fear of reprisal and on the understanding that the P.S.E.C.-PAC is engaged in joint fund-raising efforts with the AFL-CIO and will use the money contributed to that effort to make political contributions and expenditures in connection with federal, state, and local elections.   This voluntary authorization may be revoked upon 30 days written notice to the State Comptroller and P.S.E.C.-PAC.

                      SIGNATURE:_________________________________________DATE:_______________

CONTRIBUTIONS TO THE P.S.E.C.-PAC ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS FOR FEDERAL INCOME TAX PURPOSES.