Bringing dignity home., January 01, 2001, Image 3

HOMECARE MEMBERSHIP APPLICATION
SEIU LOCAL 503, AFL-CIO, CLC
OREGON PUBLIC EMPLOYEES UNION
(Press Hard; Please Print or Type Clearly)
SOCIAL SECURITY NUMBER
/
/
DATEOFBIRTH
(SDSD REQUIRES YOUR SSN TO FORWARD YOUR DUES TO SEIU LOCAL 503, OPEU)
/________ /
MONTH
NAME
YEAR
DAY
HOME PHONE
FIRST
LAST
MI
RESIDENCE ADDRESS _________________________________________________________ _ ______
(REQUIRED)
CITY
STREET
STATE
ZIP
MAILING ADDRESS ___________________ ______________________________________________
(IF DIFFERENT FROM ABOVE)
CITY
STREET
STATE
ZIP
ALTERNATE MAILING ADDRESS _ ______ _ ______________ __ ____ _________________________
(IF DIFFERENT FROM ABOVE)
CITY
STREET
WORK PHONE
EMPLOYMENT STATUS:
STATE
ZIP
E-MAIL---------------------------------------------------—
Live-In Hourly---------
I desire to be represented by SEIU Local 503, OPEU and hereby designate Senior and Disabled Services Division to deduct monthly
from my salary, wages, or other sums due me, the amount of my dues for membership in the Oregon Public Employees Union, as
provided in its Bylaws and disburse same to SEIU Local 503, OPEU.
The SEIU Local 503, OPEU Bylaws (Art. XV Sec. 9) provide for a contribution as determined from time to time by the member-elected
General Council for the benefit of the Union’s political action program. You may opt to have this contribution go to the SEIU Local 503,
OPEU Scholarship Fund instead of the political action program by checking the box at the right.
Voluntary SEIU Local 503, OPEU Political Action Checkoff
Citizen Action By Public Employees (CAPE)
□ $4.16 = 2.4<t/hour/month
□ $8.33 = 4.8C/hour/month
For financial contributions to member-endorsed candidates for Local, Legislative, and Statewide offices. These elected
officials make critical decisions on our PERS, our salaries, and laws specifically affecting SEIU Local 503, OPEU members. This
contribution qualifies for the Oregon Political Tax Credit. Single filers are eligible for a credit of up to $50 per year, joint filers
up to $100 per year.
I hereby request my employer to deduct the above amount from my monthly earnings, and to remit that amount on my behalf to
my Union — OPEU. This amount is to be a continuing monthly deduction and can be terminated by my written notice.
(This contribution is in addition to your Union dues.)
Dues and fees to SEIU Local 503, OPEU are not deductible as charitable contributions for federal income tax purposes. They may qualify
as business expenses, and may be deductible in limited circumstances subject to various restrictions imposed by the Internal Revenue Code.
Changes which may from time to time occur in state and federal law will not alter these deduction requests, unless so indicated by me.
At the time you enrolled as a client-employed provider, you were required by 42 CFR 433.37 to give Senior and Disabled Services Division
your Social Security number. Your signature below will give Senior and Disabled Services Division authorization to release your Social
Security number to SEIU Local 503, OPEU to allow SEIU Local 503, OPEU to identify and track your membership dues deduction. If you
do not wish to consent to this release, you can check the box to the right. Please do not check this box if you want to become an active
member. Your Social Security number is kept strictly confidential.
O
SIGNATURE
RETAIN BOTTOM COPY FOR YOUR RECORDS
DATE
RETURN ALL OTHER COPIES TO SEIU LOCAL 503, OPEU, PO BOX 12159, SALEM, OR 97309-0159