Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate

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1 Form W-4 (2016) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2016 expires February 15, See Pub. 505, Tax Withholding and Estimated Tax. Note: If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Is age 65 or older, Is blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A You are single and have only one job; or B Enter 1 if: { You are married, have only one job, and your spouse does not work; or... B Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more than one job. (Entering -0- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above).. E F Enter 1 if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit... F (Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $70,000 ($100,000 if married), enter 2 for each eligible child; then less 1 if you have two to four eligible children or less 2 if you have five or more eligible children. If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter 1 for each eligible child.. G H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) H { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 that apply. to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Form W-4 Department of the Treasury Whether you are entitled to claim a certain number of allowances or exemption from withholding is Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Your first name and middle initial Last name OMB No Your social security number Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note: If married, but legally separated, or spouse is a nonresident alien, check the Single box. City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2016)

2 Form W-4 (2016) Page 2 Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. 1 Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300 and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details... 1 $ $12,600 if married filing jointly or qualifying widow(er) 2 Enter: { $9,300 if head of household } $ $6,300 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter $ 4 Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) $ 6 Enter an estimate of your 2016 nonwage income (such as dividends or interest) $ 7 Subtract line 6 from line 5. If zero or less, enter $ 8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet, line H, page Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10 Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note: Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter -0- ) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet Note: If line 1 is less than line 2, enter -0- on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed.. 8 $ 9 Divide line 8 by the number of pay periods remaining in For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $ Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job are Enter on line 2 above $0 - $6, ,001-14, ,001-25, ,001-27, ,001-35, ,001-44, ,001-55, ,001-65, ,001-75, ,001-80, , , , , , , , , , , ,001 and over 15 If wages from LOWEST paying job are Enter on line 2 above $0 - $9, ,001-17, ,001-26, ,001-34, ,001-44, ,001-75, ,001-85, , , , , , , ,001 and over 10 Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. If wages from HIGHEST paying job are Enter on line 7 above $0 - $75,000 $610 75, ,000 1, , ,000 1, , ,000 1, , ,000 1, ,001 and over 1,600 If wages from HIGHEST paying job are Enter on line 7 above $0 - $38,000 $610 38,001-85,000 1,010 85, ,000 1, , ,000 1, ,001 and over 1,600 You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. 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12 Personal Care Attendant Signature Form THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services Name of fiscal intermediary (FI) All PCAs hired by a PCA consumer must fill out and sign this form and give it to their employer (the PCA consumer). The PCA s employer (the PCA consumer) must submit this form to the FI, along with all other paperwork required by the FI and MassHealth. The FI cannot pay a PCA until all required paperwork is received and complete. MassHealth and the FI cannot pay a PCA to work o when the PCA consumer is in an inpatient facility, such as a hospital or nursing facility; or o when the amount of time that has been authorized by MassHealth has been exhausted or is insufficient. The PCA must read the rest of this form and sign below before receiving payment from the FI. I agree to accept the position of personal care attendant (PCA) for (name of PCA consumer). I understand that my employer is the PCA consumer. My employer is responsible for hiring, firing, training and scheduling PCAs. My employer may select another person (a surrogate) to help manage his or her PCA services. I must notify my employer and the surrogate (if any), of any changes in my circumstances that would affect my ability to perform my duties as a PCA. I must complete and provide accurate Activity Forms (time sheets) to my employer or the FI as soon as I can. The FI will process payroll for my employer. My employer is responsible for giving the check to me (unless I requested that my check be deposited directly into my bank account). I must provide proof of my identity to my employer to complete the Employment Eligibility Verification form (Form I-9), which the Department of Homeland Security requires all employees to complete. (The FI will give my employer this form.) I understand that the MassHealth PCA program pays for personal care services provided by a PCA only when the PCA provides physical assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) to an eligible PCA consumer who has obtained prior authorization from MassHealth for PCA services. PCA services must be provided in accordance with the PCA consumer s authorized PCA evaluation or reevaluation, service agreement, and MassHealth regulations at 130 CMR I understand that ADLs include physically assisting the PCA consumer with transferring, walking, using medical equipment, taking medications, bathing and grooming, dressing and undressing, passive range-of-motion exercises, eating, and toileting. I understand that IADLs include household services that are essential to the PCA consumer s care such as laundry, shopping, housekeeping, meal preparation and cleanup, transportation to medical appointments, activities such as maintenance of wheelchairs or other medical equipment, completing the paperwork required for receiving personal care services, and other activities approved by MassHealth as being instrumental to the health care needs of the PCA consumer. I understand that my employer (the PCA consumer) will tell me which of these services require me to provide physical assistance. I understand that I cannot be paid as a PCA if I am a spouse, parent (if the PCA consumer is a minor child), surrogate, foster parent, or legally responsible relative of the PCA consumer. The following describes my relationship to my employer (the PCA consumer). (Please check one.) adult child (18 yrs. or older) of member daughter in-law of member son-in law of member parent of adult (18 yrs. or older) member other relative (describe) nonrelative (describe) I certify under pains and penalties of perjury that the information on this signature form, and any accompanying statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete to the best of my knowledge. I also certify that I understand my duties, rights, and responsibilities as a PCA and that all the information I have provided to my employer (the PCA consumer), to the fiscal intermediary, to the personal care management agency, or to MassHealth is true and accurate to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. Print PCA Name Date PCA signature PCA-S (Rev. 06/11)

13 Ayudante de atención individual Formulario para la firma THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services Nombre del intermediario fiscal (FI, por sus siglas en inglés): Todos los Ayudantes de atención individual (PCA, por sus siglas en inglés) contratados por un usuario de PCA deberán llenar y firmar este formulario y entregárselo a su empleador (el usuario de PCA). El empleador de PCA (el usuario de PCA) deberá enviarle este formulario al intermediario fiscal, junto con toda la documentación adicional que exijan el intermediario y MassHealth. El FI no podrá realizarle pagos a un PCA hasta que se haya recibido toda la documentación requerida y esta esté completa. MassHealth y el FI no podrán pagarle a un PCA por trabajar: o cuando el usuario de PCA esté internado en un hospital o centro de enfermería; o o cuando la cantidad de tiempo que MassHealth haya autorizado se haya agotado o no sea suficiente. El PCA deberá leer el resto de este formulario y firmar en el espacio siguiente antes de recibir pagos del IF. Estoy de acuerdo en aceptar el puesto de ayudante de atención individual (PCA, por sus siglas en inglés) para (nombre del usuario de PCA). Entiendo que mi empleador es el usuario de PCA. Mi empleador está a cargo de contratar, despedir, capacitar y elaborar los horarios de los PCA. Mi empleador puede escoger a otra persona (un sustituto) que le ayude a manejar los servicios de PCA. Debo notificarles a mi empleador y al sustituto (si lo hubiera) cualquier cambio en mi situación que afecte mi capacidad para desempeñar mis labores de PCA. Debo llenar y entregarle a mi empleador o al sustituto Formularios de actividad (planillas de control de horas) exactos tan pronto como pueda. El FI procesará los pagos que deba realizarme mi empleador. Mi empleador tendrá la responsabilidad de entregarme el cheque (a menos que yo haya solicitado que mi cheque se deposite directamente en mi cuenta bancaria). Tendré que proporcionarle a mi empleador prueba de mi identidad para llenar el Formulario de verificación de cumplimiento de los requisitos de empleo (Formulario I-9), que el Departamento de Seguridad Nacional (Department of Homeland Security) requiere a todos los empleados. (El FI le entregará a mi empleador este formulario.) Entiendo que el programa PCA de MassHealth solamente paga por los servicios de atención individual que preste un PCA cuando éste proporcione asistencia física para realizar actividades de la vida diaria (ADLs, por sus siglas en inglés) o actividades instrumentales de la vida diaria (IADLs, por sus siglas en inglés) a un usuario de PCA elegible que haya obtenido autorización previa de MassHealth para recibir servicios de PCA. Los servicios de PCA deberán prestarse de conformidad con la evaluación o reevaluación autorizada del usuario de PCA, con el contrato de servicios y las regulaciones de MassHealth en 130 CMR Entiendo que las ADLs comprenden asistir físicamente al usuario con las actividades cotidianas comprende ayudarle a trasladarse, a caminar, a utilizar aparatos médicos, a tomar medicamentos, a bañarse y arreglarse, a vestirse y desvestirse, a realizar ejercicios pasivos para mejorar la amplitud de movimientos, a comer y a ir al baño. Entiendo que las IADLs comprenden servicios domésticos esenciales para la atención del usuario, tales como lavar la ropa, hacer las compras, mantener la casa ordenada, preparar las comidas y recoger los platos, llevarlo a citas médicas, realizar el mantenimiento de sillas de ruedas u otros equipos médicos, llenar los documentos requeridos para recibir los servicios de atención individual y otras actividades que MassHealth haya aprobado por ser instrumentales para satisfacer las necesidades relativas al cuidado de la salud del usuario de PCA. Entiendo que mi empleador (el usuario de PCA) me informará en cuáles de estos servicios se requiere que yo le preste asistencia física. Entiendo que no me podrán pagar como un PCA si soy el cónyuge, el padre/la madre (si el usuario de PCA es un hijo menor de edad), el sustituto, el padre/la madre de crianza o el pariente legalmente responsable del usuario de PCA. La siguiente es mi relación con mi empleador (el usuario de PCA). (Por favor marque una opción.) Hijo adulto (de 18 años o más) del afiliado Nuera del afiliado Yerno del afiliado Padre/madre del afiliado adulto (18 años o más) Otro pariente (describa) No soy pariente (describa) Certifico bajo los castigos y penas de perjurio que la información que contiene este formulario para la firma y toda declaración adjunta que yo haya suministrado, han sido revisadas y firmadas por mí y son verdaderas, exactas y completas a mi mejor entender. También certifico que entiendo mis deberes, derechos y responsabilidades como PCA y que toda la información que he proporcionado a mi empleador (el usuario de PCA), al intermediario fiscal, a la agencia de administración de atención individual o a MassHealth es verdadera y exacta a mi mejor entender. Entiendo que yo podría ser objeto de sanciones de carácter civil o de denuncia penal por cualquier falsificación, omisión u ocultación de cualquier hecho fundamental incluido en este documento. Nombre del PCA en imprenta: Firma del PCA y fecha: Firma del PCA: PCA-S (Rev. 06/11)

14 EN E S V B E M V I E T O FORM M-4 MASSACHUSETTS EMPLOYEE S WITHHOLDING EXEMPTION CERTIFICATE Rev. 1/12 Print full name... Social Security no.... Print home address... City... State... Zip... DEPARTMENT OF MASSACHUSETTS S P E TI T P L A C I D A M REVENUE L IBERTATE Employee: File this form or Form W-4 with your employer. Otherwise, Massachusetts Income Taxes will be withheld from your wages without exemptions. Employer: Keep this certificate with your records. If the employee is believed to have claimed excessive exemptions, the Massachusetts Department of Revenue should be so advised. HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS 1. Your personal exemption. Write the figure 1. If you are age 65 or over or will be before next year, write If married and if exemption for spouse is allowed, write the figure 4. If your spouse is age 65 or over or will be before next year and if otherwise qualified, write 5. See Instruction C Write the number of your qualified dependents. See Instruction D Add the number of exemptions which you have claimed above and write the total Additional withholding per pay period under agreement with employer $ A. Check if you will file as head of household on your tax return. B. Check if you are blind. C. Check if spouse is blind and not subject to withholding. D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income will not exceed $8,000. EMPLOYER: DO NOT withhold if Box D is checked. I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. Date Signed... THIS FORM MAY BE REPRODUCED THE COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF REVENUE A. Number. If you claim more than the correct number of exemptions, civil and criminal penalties may be imposed. You may claim a smaller number of exemptions. If you do not file a certificate, your employer must withhold on the basis of no exemptions. If you expect to owe more income tax than will be withheld, you may either claim a smaller number of exemptions or enter into an agreement with your employer to have additional amounts withheld. You should claim the total number of exemptions to which you are entitled to prevent excessive overwithholding, unless you have a significant amount of other income. If you work for more than one employer at the same time, you must not claim any exemptions with employers other than your principal employer. If you are married and if your spouse is subject to withholding, each may claim a personal exemption. B. Changes. You may file a new certificate at any time if the number of exemptions increases. Youmust file a new certificate within 10 days if the number of exemptions previously claimed by you decreases. For example, if during the year your dependent son s income indicates that you will not provide over half of his support for the year, you must file a new certificate. C. Spouse. If your spouse is not working or if she or he is working but not claiming the personal exemption or the age 65 or over exemption, generally you may claim those exemptions in line 2. However, if you are planning to file separate annual tax returns, you should not claim withholding exemptions for your spouse or for any dependents that will not be claimed on your annual tax return. If claiming a wife or husband, write 4 in line 2. Using 4 is the withholding system adjustment for the $4,400 exemption for a spouse. D. Dependent(s). You may claim an exemption in line 3 for each individual who qualifies as a dependent under the Federal Income Tax Law. In addition, if one or more of your dependents will be under age 12 at year end, add 1 to your dependents total for line 3. You are not allowed to claim federal withholding deductions and adjustments under the Massachusetts withholding system. If you have income not subject to withholding, you are urged to have additional amounts withheld to cover your tax liability on such income. See line 5. IF THE ALLOWABLE MASSACHUSETTS WITHHOLDING EXEMPTIONS ARE THE SAME AS YOU ARE CLAIMING FOR U.S. INCOME TAXES, COMPLETE U.S. FORM W-4 ONLY.

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16 APPLICATION FOR MEMBERSHIP Membership in 1199SEIU is without regard to race, color, sex, sexual orientation, age, disability, religion, national origin, political belief or affiliation. Solicitud de Membresía: La membresía con 1199SEIU es sin prejuicio de raza, color, sexo, orientación sexual, edad, discapacidad, religión, origen nacional, creencia y afiliación política. NAME (PRINT) / NOMBRE (IMPRIMIR) ADDRESS / DIRECCIÓN CITY / CIUDAD STATE / ESTADO ZIP / CÓDIGO POSTAL HOME PHONE / TELÉFONO DE CASA CELL PHONE / CELULAR / CORREO ELECTRÓNICO SOCIAL SECURITY NUMBER / NÚMERO DE SEGURO SOCIAL BIRTHDAY / FECHA DE NACIMIENTO YES, I want to join healthcare workers across the state for a stronger voice for quality healthcare, living wages and good benefits. I hereby accept membership in 1199SEIU United Healthcare Workers East and designate 1199 to act for me as collective bargaining agent in all matters pertaining to conditions of my employment. I hereby pledge to abide by the Constitution of 1199SEIU United Healthcare Workers East. SÍ, quiero unirme a trabajadores del cuidado de la salud de todo el estado por una voz más poderosa a favor de la atención médica de calidad, sueldos dignos y buenos beneficios. Por la presente acepto la membresía con 1199SEIU United Healthcare Workers East y designo a 1199 a actuar por mí como agente de negociación colectiva en todos los asuntos relacionados a las condiciones de mi empleo. Por la presente me comprometo a cumplir con la Constitución de 1199SEIU United Healthcare Workers East. SIGNATURE / FIRMA CHECK OFF AUTHORIZATION* I hereby authorize and direct the deduction of an initiation fee from my wages or salary as required by 1199SEIU United Healthcare Workers East as a condition of my membership; and in addition thereto, the deduction of my membership dues from my wages or salary, including with respect to any union dues or fees that have been previously paid in this manner; and in addition thereto, the deduction each month an amount equal to monthly membership dues to be applied to past unpaid dues until the entire amount of unpaid past dues has been deducted and paid; and the remittance of all such deductions to 1199SEIU United Healthcare Workers East, 310 W. 43rd Street, New York, NY no later than the tenth day of each month immediately following the date of deduction, or pursuant to the date provided in the Collective Bargaining Agreement. The deduction is a voluntary act on my part. This authorization may be withdrawn pursuant to M.G.L. c A upon my giving at least sixty days notice in writing of such withdrawal to the Commonwealth or its designated fiscal intermediary and my sending a copy of such withdrawal to the 1199SEIU Dues and Membership Department at 310 W. 43rd Street 2nd Floor, New York, NY Autorización por Visto:** Por la presente autorizo y requiero la retención de un monto equivalente a la comisión de iniciación de mi sueldo o salario, como requisito de 1199SEIU United Healthcare Workers East como condición de mi membresía; y además de esto, la retención de mis cuotas de membresía de mi sueldo o salario, incluyendo con respecto a cualquier cuota o comisión sindical que haya sido previamente paga de este modo; y además de esto, la retención cada mes de un monto equivalente a las cuotas mensuales de membresía, implicando también cualquier cuota pasada no paga hasta que la cantidad entera de cuotas pasadas no pagas haya sido retenida y pagada; y la remisión de todos estos montos retenidos a 1199SEIU United Healthcare Workers East, 310 W. 43rd Street, New York, NY a más tardar el décimo día de cada mes inmediatamente siguiente a la fecha de retención, o siguiente a la fecha provista en el Convenio de Negociación Colectiva. La retención es un acto voluntario de mi parte. Esta autorización puede ser retirada según M.G.L. c A siempre y cuando yo presente al Commonwealth o a su intermediario fiscal designado un aviso por escrito con por lo menos sesenta días de antelación, y que le envíe una copia de mi retirada al 1199SEIU Dues and Membership Department en 310 W. 43rd Street 2nd Floor, New York, NY SIGNATURE / FIRMA DATE / FETCHA NAME (PRINT) / NOMBRE (IMPRIMIR) ADDRESS / DIRECCIÓN CITY / CIUDAD STATE / ESTADO ZIP / CÓDIGO POSTAL HOME PHONE / TELÉFONO DE CASA CELL PHONE / CELULAR / CORREO ELECTRÓNICO *While contributions or gifts to 1199SEIU United Healthcare Workers East are not tax deductible as charitable contributions for Federal income tax purposes, they may be tax deductible under other provisions of the Internal Revenue Code. **Si bien las contribuciones o donaciones a 1199SEIU United Healthcare Workers East no son consideradas contribuciones caritativas para propósitos fiscales e impositivos, puede que sean deducibles de los impuestos bajo otras provisiones del Código de Ingresos Internos.

17 1199SEIU POLITICAL ACTION FUND The 1199SEIU Political Action Fund 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 homecare workers and who honor the work that we do. El Fondo de Acción Política de 1199SEIU crea fuerza para los trabajadores del cuidado de la salud y domiciliario. Al unificar nuestras voces y cultivar nuestro poder político, los trabajadores del cuidado de la salud y domiciliario podemos ser defensores más poderosos de nuestros trabajos y de la gente bajo nuestro cuidado. Los políticos electos toman decisiones que afectan directamente los fondos para nuestros trabajos y los servicios que proveemos. Juntos, podemos elegir a líderes que respetan a los trabajadores del cuidado de la salud y domiciliarios y que honran el trabajo que desempeñamos. POLITICAL ACTION FUND CHECK OFF I hereby authorize 1199SEIU United Healthcare Workers East to file this payroll deduction form on my behalf with my employer to withhold $10 per month, $15 per month or $ per month and forward that amount to the 1199SEIU Massachusetts Political Action Fund, 330 W. 42nd St., 7th Floor, New York, NY 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 any union; (2) I may refuse to contribute without any reprisal; (3) The monthly contribution is only a suggestion, and I may contribute more or less without fear of favor or disadvantage from 1199SEIU or my Employer, and (4) The 1199SEIU Massachusetts 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, and local offices and addressing the political issues of public importance. (5) Only union members who are US citizens or lawful permanent residents are eligible to contribute to the 1199SEIU Massachusetts Political Action Fund. Contributions to the 1199SEIU Massachusetts Political Action Fund are not deductible as charitable contributions for federal income tax purposes. 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. This authorization shall remain in full force and effect until revoked by me in writing to the 1199SEIU Massachusetts Political Action Fund at 330 W. 42nd Street, 7th Floor, New York, NY Visto para el Fondo de Acción Política: Por la presente autorizo a 1199SEIU United Healthcare Workers East a presentar este formulario de retención de nóminas ante mi empleador, en mi nombre, para retener $10 por mes, $15 por mes o $ por mes, y transmitirle ese monto al Fondo de Acción Política de 1199SEIU Massachusetts, 330 W. 42nd St., 7th Floor, New York, NY Esta autorización está hecha voluntariamente basada en mi comprensión específica de que (1) Firmar este formulario de autorización y hacer estas contribuciones voluntarias no son condiciones de mi empleo por mi Empleador, ni de membresía con ningún sindicato; (2) me puedo negar a contribuir sin ninguna represalia; (3) la contribución mensual es simplemente una sugerencia y puedo contribuir más o menos sin temer favor o desventaja por parte de 1199SEIU o de mi Empleador, y (4) el Fondo de Acción Política de 1199SEIU Massachusetts utiliza el dinero que recibe para propósitos políticos, incluyendo pero sin limitarse a, hacer contribuciones a y asumir expensas en nombre de candidatos para puestos federales, estatales y locales, y para tratar los asuntos políticos de importancia pública. (5) Sólo los miembros de la unión que son ciudadanos estadounidenses o residentes permanentes legales califican para contribuir al Fondo de Acción Política de 1199SEIU Massachusetts. Las contribuciones al Fondo de Acción Política de 1199SEIU Massachusetts no son consideradas contribuciones caritativas para propósitos fiscales. La ley federal requiere que utilicemos nuestros mejores esfuerzos para recolectar y presentar el nombre, la dirección, la ocupación y el nombre del empleador de todo individuo cuyas contribuciones excedan $200 en un año calendario. Esta autorización permanecerá en plena vigencia y efecto hasta ser revocada por mí, por escrito, al Fondo de Acción Política de 1199SEIU Massachusetts en 330 W. 42nd Street, 7th Floor, New York, NY SIGNATURE / FIRMA DATE / FETCHA NAME (PRINT) / NOMBRE (IMPRIMIR) Would you like to receive 1199SEIU action alerts on your mobile phone? (Standard text messaging rates apply) q Yes q No Le gustaría recibir alertas de acción de 1199SEIU en su celular? (Valen las tarifas regulares de mensajes de texto) q Si q No FB.com/1199SEIU.mass FOR INTERNAL USE ONLY Card Collected by: Last Four Digits of Collector s SSN#

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