COPE Payment form

Please fill in the information requested, print and mail this form to:

NABET-CWA Local 51
433 Natoma St. Suite 220
San Francisco, CA 943103

CWA Local: 59051 Payroll Authorization Form

First Name MI Last Name SSN#
Payroll Number (if required)

CWA COPE POLITICAL CONTRIBUTIONS COMMITTEE

I hereby authorize my employer to deduct from my wages the sum of $ each pay period and to remit such amount to the Communications Workers of America Committee on Political Education Political Contributions Committee. ("CWA-COPE PCC")

THIS AUTHORIZATION IS VOLUNTARILY MADE BASED ON MY SPECIFIC UNDERSTANDING THAT:

- I am making a contribution to a joint fund-raising effort sponsored by CWA-COPE PCC and the AFL-CIO Committee on Political Education Political Contributions Committee ("AFL-CIO COPE PCC") and that CWA-COPE PCC and AFL-CIO COPE PCC will use my contributions for political purposes, including but not limited to, the making of contributions to or expenditures on behalf of candidates for federal, state, and local offices and addressing political issues of public importance.

- Federal law requires us to use our bast efforts to collect and report the name, mailing address, occupation, and the name of employer of individuals whose contributions exceed $200 in a calendar year.

- Contributions or gifts to CWA-COPE PCC and AFL-CIO COPE PCC are not deductible as charitable contributions for federal income tax purposes.

Check one: New Enrollment Change of Amount

Employee Signature _____________________________________________ Date

Email Address
        Employer
     Occupation

Federal law prohibits CWA or CWA COPE PCC from soliciting contributions from persons other than CWA members, CWA executive and administrative personnel, and their families.