RETIRED PUBLIC EMPLOYEES OF NEW MEXICO
PO BOX 20607
ALBUQUERQUE, NEW MEXICO 87154-0607

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STEP 1:  Member Information - This information is required for both dues
                              payment options in the next step.

       Name*: __________________________________________________________

    Address*: __________________________________________________________

City/St/Zip*: __________________________________________________________

      E-Mail: __________________________________________________________

   Telephone: (_______)  |___|___|___| - |___|___|___|___|  * = Required 

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STEP 2:   SELECT ONE OF THE DUES PAYMENT OPTIONS BELOW.


[ ]  PAYMENT OPTION 1: Enclose a check or money order for $24, payable
     to RPENM to cover your first years dues.  Return this form with
     your payment to the address above.  You will be billed once a year
     thereafter.
                          -----  OR  -----

[ ]  PAYMENT OPTION 2: This option is only available to those persons 
     currently receiving a monthly distribution from PERA.  Your
     signature below authorizes PERA to deduct your annual dues payment
     from your July retirement distribution until you notify RPENM &
     PERA, in writing, to cancel this deduction.  Please sign, date,
     and provide your SSN below then mail this form to the address
     above.


        Please deduct my $24 dues payment from my July retirement
        distribution unless and until I notify PERA in writing to
        cancel this deduction.  

        Signature
        Authorization*:  ____________________________________________
    	                       Signature                      Date

                  SSN*:  |___|___|___| - |___|___| - |___|___|___|___| 

                         PERA requires your full Social Security Number
                         to process the dues deduction. 
                                                           * = Required 
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