Deduction authorization

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I authorize my current Employer, and all subsequent Employers, to deduct from my wages or compensation an amount of ______ Gross wages for working dues and remit same monthly to the Secretary-Treasurer of Laborers Local Union #1140, 11000 North 72nd Street, Omaha, NE 68122. I understand that dues, contributions or gifts to Laborers Local Union #1140, are not deductible as charitable contributions for federal income tax purposes. Dues paid to the Laborers Local Union #1140, however may qualify as business expenses, and may be deductible in limited circumstances subject to various restrictions imposed by the Internal Revenue Service. This authorization shall be irrevocable for one (1) year from the date of its execution and after said one (1) year only by written notice given to the Laborers Local Union #1140 at least ninety (90) days prior to the termination of the Collective Bargaining Agreement, but otherwise shall be by its terms renewable from year to year during the term of succeeding collective bargaining agreements as provided by federal law.
Signed this __________ day of _________________________, 20________ at ___________. IA, NE, SD.
Employee X _________________________________ Social Security No. __________________________
Address _______________________________________________________________________________

No. / Street / City / State / zip

Phone No. ______________________________________ Witness ________________________________

I hereby authorize and direct each employer signatory to an agreement with the Laborers International Union of North America Local Union #1140 for whom I work to deduct from my paycheck ___________

Cents for each hour worked every pay day period and to remit such amount to the Local Union #1140 PAC Fund (PAC) at such times as other remittances are made to the Union. This authorization is voluntarily made. I understand that the signing of this authorization and the making of payments to PAC are not conditions of membership in the union or of employment with any employer, that I have a right to refuse to sign this authorization and to contribute to PAC without reprisal and that PAC will use the money it receives to make political expenditures and contributions in connection with sate and local elections. I also understand that this amount of money is merely a suggested guideline, that I am free to contribute more or less than this amount by any lawful means other than this check-off and that the union cannot favor or disadvantage me because of the amount of my contribution or my decision not to contribute. This authorization shall remain in effect until revoked by me in writing.

Contributions to Local Union #1140 PAC Fund are not deductible as charitable contributions for federal income tax purposes.
X _____________________________________________________________ _____________________

(Signature) (Date)

Executed in triplicate, with one copy for the Employer, one copy for the Laborers Local Union #1140, and one copy for the member.

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