You must be a member of SSPBA and be retired in order to complete this form.  If you fill out this form and are not a member, your information will not be processed.
 
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 Social Security Number
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County		  
State
 
Zip		  
Home Phone		  
Work Phone
 
E-mail (No work email addresses please) 

Is this a one-time deduction?

  

If yes, give deduction amount:  $
If no, choose one of the following options:
Payable to: Southern States PBA  
 

Name on Credit Card:

Credit Card Type: 
 

Credit Card Number:

If you are using an American Express Card, please enter a 0 at the beginning of the card number!

  

Expiration Date: