SUAA-UIUC Membership Form
Please make a copy to complete and mail
Membership category (Please check the most appropriate):
___Active Employee ___Retiree ___Retiree and Spouse
___Spouse ___Surviving Spouse ___Supporter
Select your option to pay dues. Dues to SUAA are not tax deductible:
1. Recommended option if you are receiving an annuity/retirement payment from
SURS: I hereby authorize the State Universities Retirement System (SURS) to deduct
each month the amount as certified by the University of Illinois at Urbana-Champaign
Chapter as the current rate of dues, The deduction is to start on the 1st of
_____________(Month) and will continue until termination is requested in writing to
SUAA. I also authorize SURS to provide change of address information to the Chapter
and SUAA.
Signature (Required) ____________________________________________________
(Please sign the copy you mail)
2. Payment by Check – Active Employees, Annuitants, Others:
Membership Dues: University of Illinois at Urbana-Champaign Chapter
SUAA will bill you on the anniversary of this membership
$30.00/yr
Optional contributions for both dues options:
SUAA Foundation optional tax deductable contribution
Make check payable to: SUAA
$________
Total
$____________
(Please Print)
Name: _________________________________________________________________
Last
First
M.I.
.Spouse - For Spouse categories __________________________________
Address: ________________________________________________________________
Street
Apt #
________________________________________________________________
State: __ __ Zip Code __ __ __ __ __ - __ __ __ __
Phone: _______________________ Email_____________________________________
Please mail to:
SUAA
3085 Stevenson Dr., Suite 301
Springfield, IL 62703