PRINT
AND MAIL THIS FORM TO THE AORP
AUTHORIZATION
AND RELEASE
I
HEREBY authorize and direct the
District of Columbia Government and the United States Government, and their
agents and employees, to release to the Association of Retired Police Officers
of D. C. Inc, upon request of an officer of AORP, such salary and/or
retirement annuity information, to include computer printouts of salary
payments, annuity payments and the method by which annuity payments were
calculated based on salary payments, as is requested by AORP, on a
continuing basis, unless and until I revoke this authorization in writing. I
hold harmless the District Of Columbia Government and the United States
Government, their agents and employees for the release of such information to
the AORP. I waive any privacy protections that may be involved with
respect to the release of this information to AORP. It is my belief that the information
requested by AORP will be used for my benefit thus, AORP is
acting as my agent in this respect.
Date: _______________
Retirees Name (Please Print):____________________________________
Retirees Social Security Number:
______________________
Agency Retiree Retired
From:____________________________________
First Date of Appointment to
Agency:______________________________
Date of Retirement from Agency:
_______________
Type of Retirement (check one): ____ Optional/Voluntary
____
Disability
Retirees
Signature:__________________________________________________
Please Print Spouses Name:___________________________________________
Signature of Spouse (Survivor
Annuitant):____________________________________
Social Security Number of
Spouse:_______________________
Your Street
Address:______________________________________________
City, State, ZIP:__________________________________________________
Telephone:
___________________________________________________
E-mail (if applicable)
______________________________________________
Please return it to:
George R. Suter, Secretary/-Treasurer at 3308 Sandburg Terrace, Olney, Maryland
20832 2531