Retiree Subsidy Authorization Form – Professional Fire Fighters of Arizona

For Members Who Participated in their departments Retiree Subsidy Program through UAFHCT

The United Arizona Firefighters Health Care Trust (UAFHCT) is a Voluntary Employees Beneficiary Association (VEBA) trust which is subject to very strict government regulations. In order to retain the tax advantages provided in a VEBA, retirees who join the Health Care Trust must meet the following:

Membership in an Arizona IAFF affiliate

Local *

Department

Participant Name *

Social Security Number *

Address *

City *

State *

Zip *

Email *

Home Phone *

Mobile Phone *

Date of Retirement *

How do you want the funds distributed? *

Direct Deposit
Mail to my address above

Name on Bank Account Registration

Bank Name

Bank Routing (ABA) Number

Bank Account Number

Comments

Signature

Date / Time

Date

Time

For Members Who Participated in their departments Retiree Subsidy Program through UAFHCT

Membership in an Arizona IAFF affiliate

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