SUAA-UIC Family* Membership
Application
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*
Two UIC Retirees or Retiree/Employee & Spouse/Significant
Other Living at Same Address
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(click
here
to go to a pdf file of this page)
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Complete this form and return it to:
State Universities
Annuitants Association (SUAA)
3085 Stevenson Drive, Suite 301
Springfield, IL 62703
Name #1: (Last)______________________
(First)____________________ (M.I.)___
E-mail address: ____________________________
UIC Annuitant____ Spouse____
Survivor of UIC Annuitant_____
UIC Employee_____ Other_____
Department affiliation at UIC_____________________
Name #2: (Last)______________________ (First)____________________ (M.I.)___
E-mail address:____________________________
UIC Annuitant_____ Spouse____
Survivor of UIC Annuitant_____
UIC Employee_____ Other_____
Department affiliation at UIC_____________________
Address:_____________________________________________________Apt.______
City:_____________________________State:____________ Zip Code:___________
Home Telephone #_______________
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 $4.16 from my monthly benefit check through December 31, 2009,
and $5.00 thereafter, and transmit it to SUAA in payment of our family membership
in the UIC chapter.
Signature
#1_________________________________________________________________ Date:_____________________
I wish to be included in the UIC SUAA family membership by virtue
of the dues payment by the other member of my household.
Signature #2_________________________________________________________________
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
$50* 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 $60