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UIC-SUAA Family* Membership Application

Name #1: (Last)________________________  (First)_______________________  (M.I.)___
E-mail address: _____________________________
(check one) UIC Annuitant____    Spouse____    Survivor of UIC Annuitant____   UIC Employee____   Other____
Department affiliation at UIC_____________________

Name #2: (Last)________________________  (First)_______________________   (M.I.)___
E-mail address:____________________________
(check one) UIC Annuitant____    Spouse____    Survivor of UIC Annuitant____    UIC Employee____    Other____
Department affiliation at UIC_____________________

Address:_____________________________________________________  Apt.______
City:_____________________________  State:____________  Zip Code:___________
Home Telephone #____________________

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

Annuitant #1, sign here: I hereby authorize the State Universities Retirement System of Illinois to deduct from my monthly benefit check the amount as certified by the UIC SUAA chapter as the current rate of dues.
Signature #1_________________________________________________________________ Date:_____________________

Name #2, sign here: 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 in the first month following receipt of this form and will continue until you inform the State Universities Retirement System otherwise.

Employees: Please submit a check payable to UIC-SUAA for $66 for 12 months of family membership or $132 for 24 months. Your membership will begin with the first month following receipt of this form.

Mail application to:

State Universities Annuitants Association (SUAA)
217 E. Monroe St., Suite 100
Springfield, IL 62701

Last modified: Dec. 15, 2010
Questions? Email suaa@uic.edu