MEMBER'$ REOUEST$HEET
'!"'FOR
DATE-
POLICY }IUMBER
Drvtst(}N NO.
SJTATION
EII,IPLOYEE No.
NO.
I\I.ATTJRE OF
FTEQUEST ACCOUNT
ACCOUNT
CODE
AMOUNT
)DEDUCT:
sroP
)Anu$T
EMPLOYEE'8 SIGhIATURE
PLEA,SS COMPLE?'E THIS FORM AND RETURN/ MAIL TO;
THE $HIEF
PROT}UCTION SUPPORT DIVISICIN ?lTA CENTER OPERATTONS nEpAnTMFNT GSIS, PAS,AY CITY I.'IOTE: YOUR REQUEST WLL TAKE EFFECT 3"MONTHS AFTER RECEIPT BY THIS OFFICE TIINCE DEPED IBM PREPARES PAYROLL 3 MONTHS INADVANCE