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)