Carewell SEIU 503 Paid Time Off packet

Paid Time Off Benefits Request
Processing timeline of Paid Time Off (PTO) payments and wage increase

Thanks to the SEIU 503 bargaining unit, care providers receive a wage increase starting January 1, 2025!

If you want your PTO at the new higher rate, you will need to request PTO on or after March 1, 2025. This is because PTO and pay rate adjustments earned in one month are not reflected in your PTO earnings until the end of the following month.

When you receive a wage increase, please make sure to account for this processing time for all future PTO benefit requests.
Securely manage your benefits online with MyCarewell503. Starting July 1, 2024, the English version of this form will be available exclusively on MyCarewell503. Learn more.
Full name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Provider number*
Number of PTO benefit hours requested*
Minimum requirement is 8 hours if you have it available in your PTO balance. Remember to check your PTO balance first before requesting.

Email*
example@example.com
Mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your physical address?*

YesNo
Physical address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred phone number*
Please enter a valid phone number.
Phone type*

Cell phoneLandline
Check this box to receive important updates from RISE Partnership about Carewell SEIU 503 benefits by text message. You may receive up to three messages per month. Standard message and data rates may apply. Reply STOP to end.

Direct deposit form

Fill out this form to sign up for direct deposit. Direct deposit is a faster and safer method than checks to get your PTO payments and reimbursements. Please provide us the following information, including a photo of a voided check. If you don't have a voided check, please submit a deposit statement from your bank or a letter from your bank with your account and routing numbers.
Bank name
Bank account number
Routing number
Using the the tool below, you must submit a copy of a voided check; or a deposit statement from your bank with your account and routing numbers; or a letter from your bank with your account and routing numbers.

Directions on how to add files

If you DO have the files on your device:
1. Click on “Add Files” on this online form
2. Select the file(s) you would like to attach/upload

If you DON’T have the files on your device:
1. Use your phone to take a photo of any forms and documents that you need to send to us. Make sure to take a complete picture of the form and that your name is included. We can’t read or use blurry photos.
2. Click on “Add Files” on this online form
3. Select the file(s) you would like to attach/add
Attach/add files*

Cancelof

PTO Benefit Designation of Beneficiary

Please complete this form to designate a beneficiary who you would like to receive your PTO benefits in the event that you pass away before receiving the benefits. You may designate one primary beneficiary, as well as one contingent beneficiary who will receive any available benefit in the event that your primary beneficiary predeceases you. Please provide the full name of your designated beneficiaries, as well as their addresses and their relationships to you.
Name of your primary beneficiary*

First NameLast Name
Beneficiary's relationship to you*
Primary beneficiary's mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary beneficiary's email address
example@example.com
Primary beneficiary's phone number
Please enter a valid phone number.

Would you like to designate a contingent beneficiary? A contingent beneficiary would receive any of your Carewell SEIU 503 PTO benefit in the event of your death if your primary beneficiary named above is also deceased.*

YesNo
Name of your contingent beneficiary

First NameLast Name
Contingent beneficiary's relationship to you
Contingent beneficiary's mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contingent beneficiary's email address
example@example.com
Contingent beneficiary's phone number
Please enter a valid phone 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 Carewell SEIU 503.
Signature*

Clear
Use your cursor or, if you are using a touchpad like on a smart phone, your finger to sign in the space above.

Form W-9: Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.
1. Name as shown on your income tax return. Name is required on this line; do not leave this line blank.*
2. Business name/disregarded entity name, if different from above
3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company.Other
If you selected "Limited liability company", enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
5. Address*

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
Requester's name (optional)

First Name
Requester's address (optional)

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
List account number(s) here (optional)

Part I - Taxpayer Identification Number (TIN)
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.
Social Security Number
or Employer identification number
Employer Identification Number is required if Social Security Number is not entered
Part II - Certification
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.
Signature*

Clear
Date*

MonthDayYear
Date
You can check out the details and general instructions below:

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 CarewellSEIU 503 Benefits.
Signature*

Clear
Use your cursor or, if you are using a touchpad like on a smart phone, your finger to sign in the space above.
Date*

MonthDayYear
Date
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.
Should be Empty:

Paid Time Off Benefits Request

Direct deposit form

PTO Benefit Designation of Beneficiary

Form W-9: Request for Taxpayer Identification Number and Certification

Part I - Taxpayer Identification Number (TIN)

Part II - Certification