JCAFT COPE

Committee on Political Education

Cope is....

----------------------------------------------------------------------------------------------------------

JCAFT COPE DEDUCTION FORM

Fill Out the Following Form, Print Page, Sign, and Send To:

Jefferson County AFT Local 2143

1900 20th Street South  *  Birmingham, AL  35209

205-933-1124 Phone  *  205-933-1101 Fax

I hereby authorize Jefferson County School District      to deduct from my salary the sum of    $2.00

                                 Leeds City Schools                                                                                               $5.00

                                 Trussville City Schools                                                                                        $10.00

                                 Vestavia Hills City Schools                                                                                 $

each per pay period and forward that amount to the Jefferson County American Federation of Teachers on Political Education (COPE Fund). This authorization is signed freely and voluntarily and not out of any fear of reprisal and I will not be favored or disadvantaged because I exercise this right.  I understand this money will be used to make political contributions by JCAFT/COPE.  **AFT/COPE may engage in joint fundraising efforts with the AFL-CIO.

Contributions or gifts to JCAFT/COPE are not deductible as a charitable contributions for federal income tax purposes

Mr/Mrs/Ms:

Social Security Number:

Address:

City: State: Zip:

Worksite: Position: Subject:

Home Phone: Cell Phone:   E-mail:

Recruiter:

Signature: ________________________________ Date: _________________

This voluntary authorization my be revoked at any time by notifying the CAFT/COPE in writing of the desire to do so