Application

CCPOA Family Defender Program

Retiree

CCPOA Benefit Trust Fund

1-800-468-6486

Full Name

(

print

)

:

Birthdate:

SSN:

Sex

:



Male



Female

Address:

City

State:

ZIP

Phone:

E-mail:

■

Program Selection



The CCPOA Family Defender Program

$13.99

Excludes Legal Defense Fund Benefits

I hereby authorize the CalPERS

to deduct from my salaries and wages the

amount specified now or in the future for membership dues and any benefit

program for which I have applied, which is sponsored by the California

Correctional Peace Officers Association (CCPOA). This authorization will

remain in effect until cancelled by me or by CCPOA. I certify that I am a retired

member of CCPOA and understand that termination of CCPOA membership

will cancel all deductions made under this authorization.

Signature of Applicant:

X

Date of Application:

RETIRED