DPCF Payroll Deduct Form .pdf

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Original filename: DPCF Payroll Deduct Form.pdf
Title: DELTA PILOTS ASSISTANCE FUND (501c)
Author: 320068

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Delta Pilot Payroll Deduction
You can return the completed form by one of three methods:
• Faxing the form to 404-763-5169,
• Emailing a scanned copy with signature to dalpafinance@alpa.org.
• Postal Mail to ALPA, 100 Hartsfield Centre Parkway, Suite 800, Atlanta, GA 30354.
• Drop off in any LEC drop box located in the pilot lounges
Please contact MEC Treasurer, Bren Fries at 800-USA-ALPA or bren.fries@alpa.org if you have any
questions.

Authorization for Payroll Deduction
$

Start a deduction from my semi-monthly pay for remittance to the DPCF.

$

Change my semi-monthly contribution to the DPCF.

Stop my semi-monthly contribution to DPCF.

Signature
Full Name:
Authorized Signature:

Date:

Employee Number:
Effective Date:
Start/Change or Stop: (must
th
th
be 15 or 30 /31st

Email Address:
Do we have your permission to feature your donation in our newsletters & online news articles?
Yes
No
Would you like to donate in Memory of someone?
Name for Memoriam
All of us at DPCF would like to thank you for your contribution to our fund.
We are a nonprofit 501c3. This contribution is tax-deductible.
Please allow one to two pay periods to take effect.


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