[Material transmitted]{.underline}

Instruction 550-2, Allotments and Assignments from Federal Employees to
Labor Organizations (pages 1-7)

Exhibit 550-2-A, HHS Form 610 (pages 1-2)

Exhibit 550-2-B, HHS Form 610A (pages 1-2)

Exhibit 550-2-C, SF 1187 (page 1)

Exhibit 550-2-D, SF 1188 (page 1)

[Material Superseded]{.underline}

Instruction 550-2 (pages 1-8: 78.9)

Exhibit X550-2-1 (pages 1-2: 78.9)

Exhibit X550-2-2 (pages 1-2: 78.9)

Exhibit X550- 2-3 (page 1: 78.9)

Exhibit X550-2-4 (page 1: 78.9)

[Background]{.underline}

1.  This Instruction replaces in its entirety the current Instruction on
    Allotments and Assignments from Federal Employees to Labor
    Organizations. There are three significant changes in the new
    Instruction. Specifically:

    a.  Under section 550-2-60, Scope, a written agreement between
        management and the labor organization for the withholding of
        dues is not required. By contrast, the old Instruction required
        that dues withholding agreements be approved in accordance with
        procedures established for the approval of all other written
        agreements.

    b.  The new Instruction is silent on the subject of charging a fee
        for dues withholding services. 5 U.S.C. 7115(a) provides that
        there will be no such cost for either the employee or the
        exclusive representative. The old Instruction provided that the
        Employee Systems Center would determine the cost per employee
        per pay period for such dues withholding service on an annual
        basis.

    c.  Under the provisions of the Executive Order, employees were
        provided the opportunity to revoke dues withholding
        authorizations at stated six-month intervals. If such provisions
        are not specifically carried over in negotiations under the
        statute} employees may not revoke the assignment of dues
        withholding for a period of one year as provided for in section
        55O-2-1OOB.1.

2.  The forms used to authorize, establish, change, or cancel the
    automatic deduction of union dues from paychecks (see Exhibit
    550-2-A and B) are scheduled to be revised into one form. when the
    revised form is issued, the Exhibits will be amended to contain the
    new form. Until the revised form is issued, the current forms should
    be used.

3.  This issuance is effective immediately. However, you are reminded of
    the obligation to implement this issuance consistent with labor
    relations responsibilities (5 U.S.C. Chapter 71 and provisions of
    negotiated agreements). Before servicing personnel offices implement
    this issuance for bargaining unit employees, they must obtain the
    concurrence of the unit's Collective Bargaining Official on a
    management position.

[Filing Instructions]{.underline}

Remove superseded material and file new material. Change Table of
Contents (Instruction 002-1) for the Personnel Manual to reflect
changes. Post receipt of this transmittal to the HHS Check List of
Transmittals and file this transmittal in sequential order after the
check list.

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Thomas S. McFee
>
> Assistant Secretary for
>
> Personnel Administration

Subject: ALLOTMENTS AND ASSIGNMENTS FROM FEDERAL EMPLOYEES TO LABOR
ORGANIZATIONS

550-2-00 Purpose and Authority

10 Coverage

20 References

30 Definitions

40 Policy

50 General Limitations

60 Scope

70 Authorization of Allotment

80 Union Accounts

90 Establishment, Change or Cancellation of a Union Dues Account

100 Mass Change, Revocation, or Discontinuance of Allotment

110 Saving Provision

120 Remittances and Reports

130 Retention of Forms and Reports

140 Distribution of Copies to HHS

Exhibit 550-2-A HHS Form 610, Authorization for Individual Union Dues
Checkoff

550-2-B HHS Form 61OA, Authorization to Establish, Change or Cancel
Union Dues Account

550-2-C SF 1187, Request for Payroll Deductions for Labor Organization
Dues

550-2-D SF 1188, Cancellation of Payroll Deductions for Labor
Organization Dues

[550-2-00]{.underline} PURPOSE AND AUTHORITY

A.  This Instruction establishes Department policies and procedures for
    the allotment of dues to a labor organization under the provisions
    of Title 5 United States Code (U.S.C.) Chapter 71, the Federal
    service labor-management relations statute.

B.  U.S.C. 7115 establishes the requirements for dues allotments to
    labor organizations in the Federal service. That section of the
    statute, as supplemented by this Instruction, constitutes the
    policies and requirements for dues allotments to labor organizations
    in the Department of Health and Human Services (HHS).[^1]

[550-2-10]{.underline} COVERAGE

This Instruction applies to all employees of the Department who are in
an appropriate unit represented by a labor organization and who have
authorized the Department, through a written assignment, to deduct
amounts from their pay for the regular and periodic dues of the
exclusive representative of the unit.

[550-2-20]{.underline} REFERENCES

A.  5\. U.S. C. Chapter 71 (law - labor-management relations)

B.  5 CHAFER. Part 297 (regulations - protection of privacy)

C.  HHS Instruction 711-1 (labor-management relations)

D.  Comptroller General Decision, B-180095, dated 10/2/75 (availability
    of appropriations for employees\' union dues)

E.  Federal Labor Relations Authority Interpretation and Guidance FLEA
    No. O-PS-1 (dues assignments)

[550-2-30]{.underline} DEFINITIONS

A.  Terms defined in 5 U.S.C. Chapter 71 and HHS Personnel Instruction
    711-1 have the same meaning when used in this Instruction (e.g.,
    Local. Labor Relations Officer).

B.  Control File - A file in the custody of the Local Labor Relations
    Officer which meets the requirements of Office of, Personnel
    Management Regulations, 5 CHAFER. Part 297, for the safeguarding of
    personnel information in manual personnel records systems.

[550-2-40]{.underline} POLICY

It is the policy of the Department that the deduction of the regular and
periodic dues of the exclusive representative of an appropriate unit
will be made in accordance with the requirements of 5 U.S.C. 7115.

[550-2-50]{.underline} GENERAL LIMITATIONS

A.  HHS Forms 610 and, 610A (Exhibits 550-2-A and 550-2-B) properly
    certified by the applicable Local Labor Relations Officer, are the
    only documents which can authorize, establish, change, or cancel the
    automatic deduction of union dues from paychecks.

B.  Dues deductions will be made on a biweekly basis only.

C.  Any payroll action requiring the use of the HHS Forms 610 and 61OA
    will not be effective sooner than the pay period in which the data
    from the forms are accepted into the Terminal Data Collection
    Service (TICS)

D.  Retroactive deductions of dues will be made only in accordance with
    the Comptroller General\'s decision B-180095, dated October 2, 1975.

[550-2-60]{.underline} SCOPE

A written agreement between management and the labor organization for
the withholding of dues is not required. It must be understood, however,
that dues will be deducted only in accordance with the procedures in
this Instruction.

[550-2-70]{.underline} AUTHORIZATION OF ALLOTMENT

A.  Action by Employees and Unions

    1.  SF 1187 (Exhibit 550-2-C) may be used to authorize allotments.
        Labor organizations, not the Department, will stock this form.
        Forms may be purchased from the Government Printing Office.

    2.  When the SF 1187 is used, the employee\'s social security number
        must be inserted in the \"Employee I.D. Number\" block. The dues
        withholding account number covering the subject employee must be
        included in the \"Name of Labor Organization\" block.

    3.  The labor organization will send the completed form to the Local
        Labor Relations Officer for processing.

B.  Action by the Local Labor Relations Officer\
    \
    The Local Labor Relations Officer will verify that the employee is
    in the bargaining unit; complete Form 610; forward the original copy
    to the servicing personnel office TICS transaction unit; forward the
    first copy to the union and retain the second copy and the SF 1187
    in the Control File.

[550-2-80]{.underline} UNION ACCOUNTS

A.  General\
    \
    Each dues withholding account number will cover only one union local
    in a bargaining unit which has the same level of dues for all
    employees. Initial amounts and changes in dues amounts will be
    reported to the Local Labor Relations Officer in accordance with
    section 550-2-90. When a union has a multiple level dues structure,
    each level will have a separate account number.

B.  Obtaining Account Numbers\
    \
    After the union has been certified by the Federal Labor Relations
    Authority as either (1) the exclusive representative for the unit
    or (2) having a valid petition showing that 10 percent of the
    employees in an appropriate unit have membership, the Local Labor
    Relations Officer will contact-the Director, Division of
    Labor-Management and Employee Relations, by telephone, and obtain a
    dues withholding account number(s).

550-2-90 ESTABLISHMENT, CHANGE OR CANCELLATION OF A UNION\
DUES ACCOUNT

A.  Establishment of an Account\
    \
    After a dues withholding account number has been assigned to the
    bargaining unit, the Local Labor Relations Officer will complete
    Form 61OA for each account and distribute it as outlined in section
    550-2-70B.

B.  Changes in Accounts\
    \
    Changes to an established account will be made by following the
    instructions on the back of Form 61OA. The Local Labor Relations
    Officer will complete Form 61OA and forward it as outlined in
    section 550-2-70B.

C.  Cancellation of an Account\
    \
    An account will not be cancelled until the Local Labor Relations
    Officer discusses the proposed action with the Operating Division
    Labor Relations Officer or the Regional Labor Relations Officer and
    the Director, Division of Labor-Management and Employee Relations.
    After such discussion, the Local Labor Relations Officer will
    complete Form 61OA; forward the original and third copies to the
    Director, Division of Labor-Management and Employee Relations, who
    will have the cancellation entered in the system at the headquarters
    office of the Employee Systems Center; forward the first copy to the
    union; and retain the second copy. Accounts will be cancelled only
    by the headquarters office of the Employee Systems Center.

550-2-100 MASS CHANGE, REVOCATION, OR DISCONTINUANCE OF\
ALLOTMENT

A.  Mass Change in Amount of Allotment

    1.  When a labor organization changes its dues, the authorized
        official of the labor organization will report such change in
        writing to the Local Labor Relations Officer who services the
        bargaining unit.

    2.  The Local Labor Relations Officer will complete Form it as
        outlined in section 550-2-70B.

    3.  The changed amount will be deducted not earlier than the first
        full pay period after the union designated effective date
        [and]{.underline} acceptance of the Form 610A data into the TICS
        system.

B.  Revocation of Allotment

    1.  An employee or labor organization may request the revocation of
        an allotment in accordance with the provisions of the negotiated
        agreement governing the bargaining unit in which the employee is
        employed or in accordance with the Interpretation and Guidance
        of the Federal Labor Relations Authority (FLRA) published in
        FLRA No. O-PS-1 dated April 19, 1979. The request must be
        submitted to the Local Labor Relations Officer. An employee may
        revoke the the allotment either by completing the SF 1188
        (Exhibit 550-2-D) or by making a written request without using
        the SF 1188. The Social Security Number must be provided in the
        written request or in the \"Employee I.D. Number\" block on the
        SF 1188. If a written request is used, it must contain all the
        information required by the SF 1188 and this subparagraph.

    2.  The Local Labor Relations Officer Will complete Form 610;
        forward the original copy to the servicing personnel office TICS
        transaction unit; forward the first copy to the union and retain
        the second copy and the employee\'s revocation request in the
        Control File. The revocation will not become effective until the
        applicable revocation date [and]{.underline} acceptance of the
        Form 610 data into the TICS.

    3.  The SF 1188 will not be carried in the Department supply system.
        It may be purchased from the Government Printing Office.

C.  Discontinuance of Allotment\
    \
    When it is determined under law and regulation that an employee or a
    labor organization is no longer eligible for dues checkoff (e.g.,
    the employee is suspended or expelled by the union or is no longer
    in the bargaining unit, or the union has lost recognition for the
    unit) the Local Labor Relations Officer will certify the action
    required by completing the applicable Form 610 or 61OA and forward
    it as outlined in section 550-2-70B or section 550-2-90C.

[550-2-110]{.underline} SAVING PROVISION

Arrangements for allotments by supervisors under the saving provision (5
U.S.C. 7135) are not subject to negotiation between management and the
labor organization concerned. Therefore, the written arrangements in
effect as of December 31, 1970 will continue to apply- for such
supervisors.

550-2-120 REMITTANCES AND REPORTS

A.  Remittance Official\
    \
    The union will advise the Local Labor Relations Officer in writing
    of the name and complete address of the official authorized to
    receive remittances and reports. The Local Labor Relations Officer
    will enter this Remittance Official information into the TICS by
    completing Form 61OA and distributing it as outlined in section
    550-2-70B.

B.  Report Preparation and Distribution\
    \
    The Pay Systems Division will submit a report biweekly in triplicate
    to the Local Labor Relations Officer named on the report showing the
    following:

    1.  Pay period number, pay period ending date, dues account number
        and date the report was prepared;

    2.  Identification of installation;

    3.  Identification of the labor organization, including the local
        number;

    4.  Name and address of Remittance Official and Local Labor Officer;

    5.  Names of employees for whom payroll deductions are made and the
        amount of the deduction. All changes in deductions from the
        previous report will be grouped at the top of the printout with
        an explanatory message for each change; and

    6.  Number of records, number of deductions, and total amount
        deducted due the union.

C.  Action by the Local Labor Relations Officer\
    \
    The Local Labor Relations Officer is responsible for checking the
    report to identify errors and to ensure that all Forms 610 and 610A
    actions authorized for that period have been effected. If such
    actions have not been effected, a follow-up will be made with the
    servicing personnel office TICS transaction unit to determine the
    reason and what action may be necessary to correct the situation. No
    actions will be effected based upon telephone calls or other oral
    arrangements. Forms 610 and 610A are the only authorized means for
    effecting checkoff actions, including the correction of errors and
    omissions. Immediately upon receipt of the report, the Local Labor
    Relations Officer will forward two copies to the union Remittance
    Official identified on the report and retain the third copy in the
    Control File.

[550-2-130]{.underline} RETENTION OF FORMS AND REPORTS

A.  Standard Forms 1187, 1188\
    \
    These forms will be retained in the Control File for as long as the
    applicable employees remain in the bargaining\' unit.

B.  HHS Form 61OA\
    \
    This form will be retained as follows:

    1.  Forms which establish or cancel accounts will be retained as
        long as the union has recognition for the applicable unit; and

    2.  Forms Which change account information will be retained as long
        as that change is applicable.

C.  Reports\
    \
    The Local Labor Relations Officer will retain a copy of all reports
    in the Control File for at least one year from the issue date.

550-2-140 DISTRIBUTION OF COPIES TO HHS

Distribution of copies to the Director, Division of Labor-Management and
Employee Relations; required by this Instruction will be addressed to
the Director, Division of Labor-Management and Employee Relations,
OS-ASPER, Department of Health and Human Services, 330 Independence
Avenue, S.W., Washington, D.C. 20201.

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

AUTHORIZED FOR INDIVIDUAL UNION DUES CHECKOFF

THIS FORM CAN BE USED TO START OR TERMINATE INDIVIDUAL UNION DUES
CHECKOFF

*(INSTRUCTION ON BACK)*

UNION ACCOUNT \# EFFECTIVE DATE

+-----------+--------------+---+-------+---+----------+----------+---------+
| NATURE    |              |   |       |   | NAME     |          |         |
+-----------+--------------+---+-------+---+----------+----------+---------+
| OF        | SOCIAL       |   | 3     | L |          | FIRST    | > MI    |
|           | SECURITY     |   | CHAR  | A |          |          |         |
| ACTION    | NUMBER       |   |       | S |          |          |         |
|           |              |   |       | T |          |          |         |
+-----------+--------------+---+-------+---+----------+----------+---------+

951.0 - START UNION DUES CHECKOFF

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

950.1 - TERMINATE: PERSON NOT IN BARGAINING UNIT

950.2 - TERMINATE: PERSON REQUESTED TERMINATION

950.3 - TERMINATE: PERSON SUSPENDED/EXPELLED FROM UNION

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

9 5 1 0 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I CERTIFY THERE IS A CURRENT AGREEMENT AS REQUIRED BY APPLICABLE CSC
REGULATION TO PERMIT DUES WITHHOLDING

FOR THIS LABOR ORGANIZATION, AND THAT ANY ADDITIONS, CHANGES, OR
DELETIONS AUTHORIZED ON THIS FORM ARE IN

ACCORDANCE WITH NEW PERSONNEL INSTRUCTION 550-2.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHORIZED SIGNATURE TITLE TELEPHONE DATE

LOCAL LABOR RELATIONS OFFICER

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

INSTRUCTIONS FOR HEW FORM 610

1.  Use typewriter only

2.  To be completed in quadruplicate

3.  Distribution:\
    \
    Original - TICS Terminal Operator\
    1st Copy - Union\
    2nd Copy - Local Labor Relations Officer\
    3rd Copy - Director, Labor Relations Staff\
    OS-OAS PER-OPT\
    Department of Health, Education, and Welfare\
    Washington, D.C. 20201

4.  Each form must have the Union Account Number, the Effective Date,
    and the certification line completed. The Certification must be
    signed by the Local Labor Relations Officer, or the person acting in
    the absence of the LLRO.

5.  One form may be used to Start and/or Terminate more than one person
    on checkoff, provided the effective date and union account number
    are the same for all persons.

6.  To START checkoff, use only the lines preceded by the Nature of
    Action Code 951.0

7.  To TERMINATE checkoff, use only the lines preceded by the Nature of
    Action Code 950, and add either 1, 2, or 3 to the Nature of Action
    Code as follows:\
    1 - If the person is not in the bargaining unit\
    2 - If the person requested termination\
    3 - If the person is suspended or expelled from the union

8.  Ensure the social security number and then the first three
    characters of the last name are within the designated blocks.

9.  To change a person from one union account number to another, use
    Nature of Action Code 951-0; do not terminate the employee from the
    old union account number \-- the new start will automatically
    terminate the person from the old account.

10. The effective date should be the first day of the pay period in
    which the action is to be effected.

11. Telephone numbers should be the FTS number. However, if you are not
    on FTS, include the area code with your commercial number.

12. No checkoff will be authorized against a union dues account until
    the account, itself, has been established. Accounts can be
    established only by an HEW Form 610a.

13. If an employee is changed from one Appointing Office in HEW to
    another in HEW, that person's checkoff will Be automatically
    terminated. Checkoff is not transferable. If checkoff is appropriate
    at the new Appointing office, a new HEW 610 must be submitted.

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

AUTHORIZATION TO ESTABLISH, CHANGE, OR CANCEL UNION DUES ACCOUNT

(*INSTRUCTIONS ON BACK)*

UNION ACCOUNT NUMBER LAIRS IDENTIFICATION \_

ESTABLISH ACCOUNT EFFECTIVE DATE

CHANGE ACCOUNT

CANCEL ACCOUNT

HEW ORGANIZATION TITLE

CITY STATE

UNION NAME AND LOCAL NUMBER

REMITTANCE AMOUNT FEE AMOUNT

REMITTANCE OFFICAL'S NAME

MAILING ADDRESS LINE 1

LINE 2

STREET ADDRESS

CITY STATE ZIP

LOCAL LABOR RELATIONS OFFICER'S INFORMATION

OFFICER'S NAME

OFFICER'S TITLE

MAILING ADDRESS LINE 1

LINE 2

STREET ADDRESS

CITY STATE ZIP

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I CERTIFY THERE (IS/IS NOT) A CURRENT AGREEMENT AS REQUITED BY
APPLICABLE CSC REGULATIONS TO PERMIT DUES

WITHHOLDING FOR THIS LABOR ORGANIZATION, AND THAT ANY ADDITIONS,
CHANGES, OR DELETIONS AUTHORIZED ON THIS FORM ARE IN ACCORDANCE WITH HEW
PERSONNEL INSTRUCTION 550-2.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHORIZED SIGNATURE TITLE TELEPHONE DATE

LOCAL LABOR RELATIONS OFFICER

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

HEW 610a (6/77)

1.  Use typewriter only.

2.  To be completed in quadruplicate.

3.  Distribution:\
    \
    Original - TICS Terminal Operator\
    1st Copy - Union\
    2nd Copy - Local Labor Relations Officer\
    3rd Copy - Director, Labor Relations Staff\
    OS-OASPER-OPT\
    Department of Health, Education, and Welfare\
    Washington, D.C. 20201

4.  Each form must have the Union Account Number, the LAIRS
    Identification Number, and the certification line completed. The
    Certification must be signed by the Local Relations Officer, or the
    person acting in the absence of the LLRO Union Account and the LAIRS
    Identification numbers are obtained by telephone from the Director,
    Labor Relations Staff, HEW.

5.  Ensure that information provided is restricted to the number of
    characters (including spaces) provided; abbreviate if necessary to
    fit. Always use the Postal Service abbreviation for states.

6.  Check which one of the three actions (Establish, Change or Cancel)
    you are requesting.

7.  HEW Organization Title - Begin with the initial caps designation of
    the Primary National Subdivision (ED, HCFA, PHS, SSA, or OS), then
    the initial caps of the constituent agency or bureau, followed by
    the name of the installation.

8.  Union Name and Local Number - Use initial caps designation for the
    union name.

9.  Remittance Amount - Enter the dollars and cents amount of biweekly
    dues deduction.

10. Fee Amount - Enter the cents amount of the biweekly; if there is no
    fee, enter two zeros.

11. Mailing Address - Always use the street address line. Line 1 and
    Line 2 are used only to further clarify the mailing address, if
    necessary.

12. When the action is to "Establish Account," all items must be
    completed.

13. When the action is to "Change Account," only that item that is to be
    changed should be filled in. If an address is changed, complete the
    entire address, not just a single line.

14. DO NOT cancel any union account until you have obtained the approval
    of the applicable PNS Labor Relations Officer and the Director,
    Labor Relations Staff, HEW.

15. Telephone numbers should be the FTS number. However, if you are not
    on FTS, include the area code with you commercial number

.

**REQUEST FOR PAYROLL DEDUCTIONS**

**FOR LABOR ORGANIZATION DUES**

**Privacy Act Statement**

Section 5525 of Title 5 United States Code (Allotments of Pay) permits
Federal agencies to collect this information. This completed form is
used to request that labor organization dues be deducted from your pay
and to notify your labor organization of the deduction. Completing this
form is voluntary, but it may not be processed if all requested
information is not provided.

This record may be disclosed outside your agency to: 1) the Department
of Treasury to make proper financial adjustments; 2) a Congressional
officer if you make an inquiry to that office related to this record; 3)
a court or an appropriate Government agency if the Government is party
to a legal suit; 4) an appropriate law enforcement agency if we become
aware of a legal violation; 5) an organization which is a designated
agent of a particular labor organization; and 6) other Federal agencies
for management, statistical and other official functions (without your
personal identification).

Executive Order 9397 allows Federal agencies to use the social security
number (SSN) as an individual's identifier to avoid confusion caused by
employees with the same or similar names. Supplying your SSN is
voluntary, but failure to provide it, when it is used as the employee
identification number, may mean that the payroll deductions cannot be
processed.

Your agency should provide an additional statement if it used the
information furnished on this form for purposes other than those
mentioned above.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1\. Name of Employees *(Print\--Last, First, Middle)* 2. Employee I.D.
Number (*SSN or Other*) 3. Timekeeper Number

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

4\. Home Address (*Street Number, City, State and ZIP Code)* 5. Name of
Agency (*Includes Bureau, Division, Branch or Other Designation)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Section A\--For Use By Labor Organization**

Name of Labor Organization (*Includes Local, Branch, Lodge or Other
Appropriate Identification)*

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

I hereby certify that the regular dues of this organization for the
above named member are currently established at
\$\_\_\_\_\_\_\_\_\_\_\_\_\_ per (biweekly

pay period) (calendar month). (*Strike out whichever period is not
appropriate, based on arrangement with the employee's agency.)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature and Title of Authorized Official Date (*Month, Day, Year)*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Section B \-- Authorization By Employee**

I hereby authorize the above named agency to deduct from my pay period,
or the first full pay period of each month, the amount certified above
as the regular dues of the (Name of Labor Organization)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
and to remit such amount to that labor organization in accordance with
its arrangements with my employing agency. I further authorize any
change in the amount to be deducted which is certified by the above
named labor organization as a uniform change in its dues structure.

I understand that this authorization, if for a biweekly deduction, will
become effective the pay period following its receipt in the payroll
office of my employing agency; and that, if for a monthly deduction, it
will become effective the first full pay period of the calendar month
following its receipt in the payroll office of my employing agency. I
further understand that Standard Form 1188, Cancellation of Payroll
Deductions for Labor Organization Dues, is available from my employing
agency, and that I may cancel this authorization by filing Standard Form
1188 or other written cancellation request with the payroll office of my
employing agency. Such cancellation will not be effective, however,
until the first pay period which begins on or after the next established
cancellation date of the calendar year after the cancellation is
received in the payroll office.

Signature of Employee Date (*Month, Day, Year)*

FOR COMPLETION BY AGENCY ONLY \--The above named employee and labor
organization meet the requirements for dues YES NO

withholding. (Mark the appropriate box. If "Yes", send this form to
payroll. If "No", return this form to the labor organization.)

ó U.S. GOVERNMENT PRINTING OFFICE : 1979 0-267-825 For sales by the
Superintendent of Documents, U.S. Government Printing Office

Washington, D.C. 20402 (per 100 sets)

Stock Number 022-000-00173-6

+------------+---------------------------------------------------------+
| Standard   | **CANCELATION OF PAYROLL DEDUCTIONS**                   |
| Form 1188  |                                                         |
|            |                                                         |
| Revised    |                                                         |
| January    |                                                         |
| 1979       |                                                         |
+------------+---------------------------------------------------------+
| Office of  | **FOR LABOR ORGANIZATION DUES**                         |
| Personnel  |                                                         |
| Management |                                                         |
|            |                                                         |
| FPM        |                                                         |
| Chapter    |                                                         |
| 559        |                                                         |
+------------+---------------------------------------------------------+

**Privacy Act Statement**

Section 5525 of Title 5, United States Code (Allotments and Assignments
of Pay) permits Federal agencies to collect this information. This
completed form is used to stop labor organization dues from being
deducted from your pay and to notify the labor organization that the
dues will be no longer deducted. Completing this form is voluntary, but
it may not be processed if all requested information is not provided.

This record may be disclosed outside your agency to: 1) the Department
of Treasury to make proper financial adjustments; 2) a Congressional
office if you make an inquiry to that office related to this record, 3)
a court or an appropriate government agency if the Government is party
to a legal suit; 4) to an appropriate law enforcement agency if we
become aware of a legal violation; 5) an organization which is a
designated collection agent of a particular labor organization, and 6)
other Federal agencies for management, statistical and other official
functions (without your personal identification).

Executive Order 9397 allows Federal agencies to use the Social Security
Number (SSN) as an individual identifier to avoid confusion caused by
employees with the same or similar names. Supplying your SSN is
voluntary, but failure to provide it, when it is used as the employee
identification number, may mean that this payroll action cannot be
processed.

Your agency shall provide an additional statement if it uses the
information furnished on this form for purposes other than those
mentioned above.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

1\. Name of Employee (Print\--Last, First, Middle) 2. Employee I.D.
Number (Social Security or other)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Agency Name (Include Bureau, Division, Branch, or other Designation)
4. Timekeeper Number

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5\. Name of Labor Organization 6. [^2] Cancellation Date (Completed by
agency only)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

I hereby cancel my authorization for the deduction of dues for the above
labor organization from my pay.\* I understand that this cancellation
will become effective on the first full pay period which begins on or
after the next established cancellation date (indicated above) after
this request is received in my agency payroll office.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. Signature of Employee 8. Date (Month, Day, Year)

(Submit copies 1 and 2 to the agency payroll office. Copy 1 is retained
for payroll records and Copy 2 is forwarded by the payroll office to the
labor organization in accordance with the arrangement between the agency
and the labor organization. Copy 3 is retained by the employee.)

[^1]: ^.^ Responsible Office: Division of Labor-Management and Employee
    Relations, Office

    of the Assistant Secretary for Personnel Administration, HHS (FTS
    245-0451)

[^2]: ^é^

    GPO : 1979 0-369-464 (T5)