To: State Controller and General Treasurer:

This is to authorize you to deduct from my salary each biweekly pay period the amount indicated above and to pay this amount as a bi-weekly contribution to the organization I have designated.

This authorization is to be effective as soon as received by you from this organization and is to remain in effect until I notify this organization in writing 60 days in advance of its cancellation.

I hereby authorize this organization to act as my Agent in the filing of this authorization with the State Controller.