NAME: ______________________________ IAFF #:_________________

ADDRESS: __________________________ CITY/ZIP_________________

LOCAL#:___________________ PHONE #: _________________________

I/we hereby authorize The Professional Firefighters of Idaho to initiate debit entries to my/our [ ] Checking [ ] Savings account (select one) as indicated below, and the financial institution named below (“Bank”), to debit same to such account.

Local #______ PAC ______________________

PFFI PAC ________________________________

IAFF FirePAC _____________________________

BANK NAME: ___________________________ BRANCH: ___________________

ADDRESS: _____________________________ CITY/ZIP: __________________

PHONE #:_______________________

ROUTING (ABA) #: ___________ ACCOUNT #: _______________________________

This authorization is made voluntarily upon my specific understanding that:

(1) The signing of this authorization card and the making of these voluntary contributions are not
conditions of membership in the union or of employment by my employer;
(2) I may refuse to contribute without reprisal;
(3) And that FIREPAC, which is connected with the International Association of Fire Fighters, uses money received for political purposes, including, but not limited to making direct contributions to candidates, conducting expenditures on behalf of candidates and addressing political issues of public importance.

This authority is to remain in full effect until The Professional Firefighters of Idaho and D. L. Evans Bank have received written notification from me (or either of us) of its termination in such time and in such manner as to afford The Professional Firefighters of Idaho and D. L. Evans Bank a reasonable opportunity to act on it.

Each year different incentive gifts (e.g. challenge coin, flashlight, etc.) are offered to members of the PFFI PAC. Would you like your gift for this year?
[ ] Yes.
[ ] No, keep it and use my money for political action.

NAME (S): ____________________________________________________

SIGNED: _________________________________ DATE: ______________


Please attach a voided check from selected bank account here.


Political contributions are not deductible for federal or Idaho state income tax purposes.