Read the following terms of agreement and check the appropriate box on the form to agree as a new Home Care Member:
1.) Membership Authorization
Yes, I want to join with my fellow PCAs and become a member of New England Health Care Employees Union, District 1199/SEIU (the Union). I hereby request and voluntarily accept membership in the Union and designate the Union to act as my exclusive representative in all matters pertaining to bargaining with the State under Connecticut Public Act 12-33. I pledge to abide by the Constitution and Bylaws of the Union.
2.) Dues Deduction/Checkoff Authorization
I recognize the need for a strong union and believe everyone represented by our union should pay their fair share. I hereby request and voluntarily authorize the PCA Workforce Council or its designee to deduct an amount equal to regular monthly membership dues and to remit such amount to the Union, as provided in the Collective Bargaining Agreement. This authorization shall remain in effect and shall be irrevocable unless I revoke it by sending written notice with my signature to the Union via U.S. mail during the period not less than thirty (30) and not more than forty-five (45) days before the annual anniversary date of this authorization or the date of termination of the applicable contract between the PCA Workforce and the Union, whichever occurs sooner. This authorization shall be automatically renewed as an irrevocable check-off from year to year unless I revoke it in writing during the window period, even if I have resigned my membership in the Union.
Contributions or gifts to SEIU are not tax deductible as charitable contributions. However, they may be tax deductible as ordinary and necessary business expenses.
3.) Direct Pay Authorization
In the event the PCA Workforce Council ceases payroll deductions, I authorize the Union to make withdrawals from my checking or savings account, in accordance with the authorization provided below. The Union will notify me of the transition to direct pay at the current mailing address on file with SEIU prior to initiating the first payment via debit card, credit card, checking, or savings account, as authorized below. I hereby authorize the Union to initiate a recurring, automatic electronic funds transfer with my financial institution beginning on the date listed in the transition notice provided to me in order to deduct from the account designated below 2.25% of my pay period gross earnings on the date of my next pay period . The dues amount may change if authorized according to the requirements of the Union’s Constitution and Bylaws or the Service Employees International Union Constitution and Bylaws. If this happens, I authorize the Union to initiate a recurring, automatic electronic funds transfer in the amount of the new dues amount when notified by the Union in writing of the new amount and with at least ten (10) days’ notice before the next funds transfer date. In the case of checking and savings accounts, adjusting entries to correct errors are also authorized. I agree that these withdrawals and adjustments may be made electronically and under the Rules of the National Automated Clearing House Association. This authorization shall remain in effect until I revoke my authorization in writing to the Union via U.S. mail or other permitted method. I acknowledge that failure to pay my dues on a timely basis may affect my membership standing in the Union, as set forth in the SEIU Constitution and Bylaws.
Contributions or gifts to SEIU are not tax deductible as charitable contributions. However, they may be tax deductible as ordinary and necessary business expenses.
- Direct Deposit Account Information Authorization
I authorize the Union to make withdrawals from the financial account where I receive direct deposit of my paycheck, and I authorize the PCA Workforce Council or its designee to provide the Union’s designated secure payment processor the information for the Account (account number, account holder’s name and routing number) on file that I have designated to receive the proceeds of my paycheck via direct deposit. If direct deposit of my paycheck goes to both a checking and a savings account, I hereby authorize the PCA Workforce Council or its designee to provide the Union’s designated secure payment processor the information for the checking account and for my dues and/or other contributions to be deducted from this account. The Union will make reasonable efforts to contact me to confirm the accuracy of the Account information provided by the PCA Workforce Council or its designee at least 10 days in advance of making the first electronic funds transfer from my Account.
4.) Yes! I want to hold politicians accountable to working families and I know we can only do that if we stand together.
$20/MONTH $15/MONTH $10/MONTH
I hereby authorize the State of Connecticut or its designee to withhold the indicated amount per month to forward to the Union as a contribution to District 1199 Political Action Committee/SEIU (1199 PAC). My signature shows that I agree with the terms below. In the event the PCA Workforce Council ceases or is unable to make my 1199 PAC contributions via payroll deduction, I hereby authorize the Union to initiate a recurring, automatic electronic funds transfer with my financial institution beginning on the date listed in the transition notice provided to me in order to deduct from the account provided to the Union’s designated secure payment processor the indicated amount per month on the day of each month on which my dues are deducted as indicated above and to transmit to the Union as a contribution to 1199 PAC. My signature shows that I agree with the terms below.
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 District 1199 Political Action Committee/SEIU (1199 PAC), part of which is remitted to SEIU COPE, as a condition of my employment or membership in the union; 2) I may refuse to contribute without reprisal; 3) Under law, only union members who are U.S. Citizens or lawful permanent residents are eligible to contribute to 1199 PAC; 4) The contribution amounts on this form are merely suggestions, and I may contribute more or less by this or other means without fear of favor or disadvantage from the Union or the PCA Workforce Council; 5) 1199 PAC 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 political issues of public importance. This authorization shall remain in effect until revoked by me in writing via U.S. mail to the Union.
Contributions or gifts to 1199 PAC are not tax deductible as charitable contributions.
