1199 Massachusetts Political Action Fund Checkoff Authorization

The 1199SEIU Massachusetts Political Action Committee builds strength for healthcare and homecare workers. By uniting our voices and growing our political power, healthcare and homecare workers can be stronger advocates for our jobs and the people in our care. Elected officials make decisions that directly impact funding for our jobs and the services we provide. Together, we can elect leaders who respect healthcare and home care workers and who honor the work that we do.

This authorization is made voluntarily based on my specific understanding that:

1. I am not required to sign this form or make voluntary contributions to the 1199SEIU Massachusetts Political Action Committee as a condition of my employment or membership in the union;
2. I may refuse to contribute without reprisal;
3. The contribution amounts on this form are merely suggestions, and I may contribute more or less by this or other means without fear or disadvantage from 1199SEIU or my employer;
4. The 1199SEIU Massachusetts Political Action Committee uses the money it receives for political purposes, including but not limited to, making contributions to and expenditures on behalf of candidates for federal, state, and local offices and addressing the political issues of public importance; as allowable under applicable law;
5. My contribution is subject to the limits and prohibitions of the Massachusetts Campaign and Finance law.

Contributions to the 1199SEIU Massachusetts Political Action Committee are not deductible as charitable contributions for federal income tax purposes.

Massachusetts state law requires we collect the name and address for every contribution and the occupation and employer for those whose contributions exceed $200 in a calendar year.

This authorization shall remain in full force and effect until revoked by me either electronically by sending an email to [email protected] or in writing to the 1199SEIU Massachusetts Political Action Committee, 108 Myrtle Street, Suite 400, Quincy Massachusetts, 02171.

Political Action Fund Checkoff Authorization

This authorization is made voluntarily based on my specific understanding that:

1. The signing of this authorization form and the making of these voluntary contributions are not conditions of my employment by my Employer or membership in my Union; 2. I may refuse to contribute without any reprisal; 3. Any guideline amount is merely a suggestion, and I will not be favored or disadvantaged because of the amount of my contribution or my decision not to contribute; and 4. The 1199 SEIU United Healthcare Workers East Federal Political Action Fund uses the money it receives for political purposes, including but not limited to, making contributions to and expenditures on behalf of candidates for federal, state, local offices and addressing political issues of public importance. 5. Contributions to the 1199 SEIU United Healthcare Workers East Federal Political Action Fund are not deductible as charitable contributions for federal income tax purposes. 6. This authorization shall remain in full force and effect until revoked by me either electronically by sending an email to [email protected] or in writing to the 1199SEIU Political Action Department at PO Box 2665, New York, NY 10108.

Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year.