RETIRED EMPLOYEE’S AUTHORIZATION FOR CHECK-OFF OF DUES I hereby assign to the International Union, United Automobile, Aerospace and Agricultural Implement Workers of America (UAW), from any monthly retirement benefits payable to me as a retired employee under a Retirement Plan established by agreement between ___________________________________________________ and the International Union, UAW, the sum of $3.00 or more _______ as monthly membership dues. I authorize and direct that such amounts be deducted from my monthly retirement benefits, and be remitted to the Union at such times and in such manner as may be agreed upon by you and the Union while this authorization is in effect. This assignment, authorization and direction shall remain in full force and effect until written revocation is received by the Company and the Union. This authorization is made pursuant to the provisions of Section 302(c) of the Labor Management Relations Act of 1947, as amended.

Contributions or gifts to the UAW are not deductible as charitable contributions for Federal Income Tax purposes.

Name - Type or Print Name

Local Union No.

Street

Social Security No.

City Phone Return to: UAW Retired Workers Dept. 8000 E. Jefferson - Detroit, MI 48214

Region

State

Zip Rev. 07/14 FORM RW 1221

Email

Signature of Retired Employee here