Using one of the tools below, please either take a photo or upload a file of one of the following: a voided check; or a deposit statement from your bank with your account and routing number; or a letter from your bank with your account and routing number.
By my signature below, I hereby designate the above individual as my Primary Beneficiary for the purpose of receiving any Carewell SEIU 503 Paid Time Off benefit payable on my behalf in the event of my death. Further, I hereby revoke any prior designation of Primary Beneficiary. I understand that this beneficiary designation will become effective only upon its receipt by the Benefits Administrative Office.
By my signature below, I hereby designate the above individuals as my Primary and Contingent Beneficiaries for the purpose of receiving any Carewell SEIU 503 Paid Time Off benefit payable on my behalf in the event of my death. Further, I hereby revoke any prior designation of Primary or Contingent Beneficiaries. I understand that these beneficiary designations will become effective only upon receipt by the Benefits Administrative Office.
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your Social Security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
I understand that by completing and signing this form I am requesting a taxable income benefit. I also understand that Paid Time Off (PTO) benefits will not be paid to me unless I have submitted a completed Form W-9 to the Benefits Administrative Office. I understand that any PTO benefit that I have accrued in a calendar year but have not applied to receive will be cashed out to me on February 15th of the following year so long as I have submitted a completed W-9 form to the Benefits Administrative Office by January 31st.
In February-March and July-August, PTO Benefit Request Forms are processed once a month. Forms received by the 20th of the month will be processed for payment by the end of the month.
For all other months, PTO Benefit Request Forms are processed on the following schedule:
- Forms submitted by the 5th of the month will be processed for payment on the 15th of the month.- Forms submitted between the 6th and the 20th of the month will be processed for payment on the last Friday of the month.- Forms submitted after the 20th of the month will be processed for payment on the 15th of the following month.
Please allow 5-10 business days for the payment to arrive.