UNITE HERE! TIP Campaign Committee

UNITE HERE! TIP Campaign Committee
CHECK-OFF AUTHORIZATION FOR POLITICAL CONTRIBUTIONS FROM WAGES
I Full name* hereby authorize and direct the payroll department of Employer* to deduct from my salary the sum of $ dollar amount* monthly and to transmit that sum to the UNITE HERE TIP Campaign Committee. I understand that (1) my contributions will be used for political purposes to advance the interests of the members of UNITE HERE, their families, and all workers, including support of federal and state candidates and political committees and addressing political issues of public importance; (2) contributing to the UNITEHERE Tip Campaign Committee is not a condition of membership in UNITE HERE or any of its affiliates, or a condition of employment; (3) I may refuse to contribute without reprisal; and (4) any guideline contribution amounts proposed by UNITE HERE are only suggestions; I may contribute more or less than those amounts, and I will not be favored or disadvantaged by UNITE HERE because of the amount of my contributions or my decision not to contribute.
Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
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. Only U.S. citizens and lawful permanent residents who are UNITE HERE members or UNITE HERE executive or administrative staff, or their family members, may contribute.

Contributions or gifts to the UNITE HERE TIP Campaign Committee are not tax deductible.
Should be Empty: