HTML version of the form: Application for the Refund of Union Dues

(Block Letters)

Part I - To be Completed by the Employing Department

• To: (Union mailing address):
• From: (Department mailing address):

Authority is requested to refund union dues through the pay system to the employee shown below for the period and reason indicated.

• Family name:
• Initials:
• Department code:
• Pay office:
• Paylist:
• IAN:
• BUD code:
• Classification:
• Geographic location:

Period of Overpayment

• From
  • MM:
  • YYYY:
• To
  • MM:
  • YYYY:

Calculated Amount of Refund to Employee

• No. of Months:
• Monthly amount: $
• Total refund: $

Reason for the refund (supporting document(s) to be enclosed):

Department Representative

• Name:
• Signature:
• Telephone number:
• Facsimile:
• Date
  • YYYY:
  • MM:
  • DD:

Part II - To be Completed by the Bargaining Agent

This application for a refund through the pay system is:

• Approved in full
• Approved partially (see reason(s) below)
  • Amount approved: $
• Denied (see reason(s) below)

Reason(s):

Authorized Bargaining Agent Official

• Name:
• Signature:
• Telephone number:
• Date
  • YYYY:
  • MM:
  • DD:

TBS/SCT 340-50 (2003/09)