SURVIVING SPOUSE AUTHORIZATION FOR CHECK-OFF OF DUES (ASSOCIATE STATUS) TO: CHRYSLER, Trustee under the Chrysler-UAW Retirement Plan, and any Successor Trustee(s).

Date__________________

I hereby assign to the International Union, United Automobile, Aerospace and Agricultural Implement Workers of America (UAW), (hereinafter referred to as the “Union”) from any wages earned or to be earned by me as your employee or as a Surviving Spouse, including any pension payable to me, associate dues donations in the amount of Three Dollars ($3.00) or more _______. I authorize and direct that such amounts be deducted from my pension each month and be remitted to the Union at such times and in such manner as may be agreed upon between 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 Corporation and the Union or until the termination of the applicable collective bargaining agreement between the Corporation and Union that is in force at the time of delivery of this authorization and I agree and direct that this assignment, authorization and direction shall be automatically renewed for the period of each succeeding applicable collective agreement between the Corporation 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 of Surviving Spouse - Type or Print Street Address

Local Union No. City

E-Mail

State

Phone

Name & Social Security No. of Deceased Retired Worker

Surviving Spouse Social Security No.

Signature of Surviving Spouse

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

Region

Zip

UAW CHRYSLER Ret. Surv. Sp. Rev. 07/14 FORM RW 1020