SUAA-UIC Membership Application

(click here to go to a pdf file of this page - requires Adobe Reader )

Note: Two SURS members or annuitants living in the same household may join as "family" members. Click here to go to the SUAA-UIC Family Membership Application.

Complete this form and return it to:

State Universities Annuitants Association
3085 Stevenson Drive, Suite 301
Springfield, IL 62703

Name: (LAST)___________________________ (FIRST)________________________ (M.I.)____
Address: ______________________________________________________ Apt. #__________ City:_____________________________State:____________ Zip Code:___________
Home Telephone #_____________________ E-mail address:_________________________

UIC Annuitant____        Survivor of UIC Annuitant____         UIC Employee_____         Other_____

Department affiliation at UIC_____________________        Spouse_____________________

If you want your SUAA dues deducted from a monthly SURS annuity check, check here__ and sign below:

I hereby authorize the State Universities Retirement System of Illinois to deduct from my monthly benefit check the amount as certified by the SUAA-UIC chapter as the current rate of dues.

Signature:___________________________________________________ Date:_____________________

Monthly deductions will begin on the first month following receipt of this form and will continue until you inform the State Universities Retirement System otherwise. Otherwise, submit a check for $30* payable to SUAA-UIC. This will pay your dues for the ensuing 12-month period. Similar payments will be required each year to continue your membership.

* after December 31, 2009, the dues will be $36