SEIU 1199NE Settlement W-9

Final Resolution of 1199 NLRB Cases Against CareOne/HealthBridge Facilities in CT

1199 Bargaining Unit Members who worked at certain former CT CareOne/HealthBridge facilities during 2010-2013 may be a part of a monetary settlement relating to various NLRB unfair labor practice cases that began during that time period. These facilities include:

Danbury Health Care
Long Ridge of Stamford
Newington Health Care
West River Health Care
Westport Health Care
Wethersfield Health Care

In order to determine your possible eligibility for participation in the settlement and to facilitate and coordinate this process, please provide the following information to the Union.

If you are determined to be part of the settlement, in order to receive a settlement check, You Must First Complete a Federal W-9 Tax Form Using this included online form.

If you need further assistance, contact Suzanne Clark via email at sclark@seiu1199ne.org or at the 1199NE office at 1-800-922-1768 ext 6026 or direct dial at 860-251-6026.

Sometime during 2010–2013 I worked at

Select every facility that applies. 1199NE uses this to confirm you are part of the settlement.

You are completing an IRS Form W-9 on a mobile platform.
What you enter here generates an official Form W-9, which you will review and sign
before submitting. Your Social Security number is required by the IRS for this form.

Name (as shown on your income tax return)

First

Middle (optional)

Last

Line 1 of Form W-9. Must match the name on your tax return.

Federal tax classification

Line 3a. Check the one box that matches how you file your taxes. Most people should choose Individual / sole proprietor.

If you are eligible for a settlement check, how would you like to receive it?

Have it mailed by USPS Certified Mail, signature required, to the address provided in the next section
Pick it up in person at the 1199 office, 77 Huyshope Ave, Hartford CT

Please note: pick up times are anticipated to be scheduled at the beginning of October; eligible members who have completed the required W-9 Tax Form will be notified of pickup dates and times. All other members will be contacted at a later date regarding alternative pick up times.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Lines 5 and 6. Your address as it should appear on Form W-9. If you asked for your check by mail, this is where it will be sent.

Phone number

Email address

Social Security number

Part I. Format: 123-45-6789

Almost done. Read the certification below and sign. On the next
page you will see your completed Form W-9 to check before you submit it.

eligible Social tax

Part II — Certification

Under penalties of perjury, I certify that:

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
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
I am a U.S. citizen or other U.S. person; and
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.

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Signature of U.S. person

Clear Signature

Sign with your finger or mouse. By signing you certify the statements above under penalties of perjury.

Check your Form W-9 below. This is what will be sent to the union.
If anything is wrong, go back and correct it before you submit.

Go back and sign to see your completed Form W-9.