IRONWORKERS 28 Reciprocal

IRON WORKERS

INTERNATIONAL RECIPROCAL AGREEMENT AUTHORIZATION OF CONTRIBUTIONS TRANSFER
Contractor*
Start Date*

MonthDayYear
Date
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone:*
SSN: *
Date of Birth: *

MonthDayYear
Date
Home Local #*
Union Book Number: *
I hereby elect or do not elect as indicated below, to have contribution which are paid on my behalf to the following Funds, transferred to my Home Local. I understand that this Authorization is only valid with respect to those Cooperating Funds that have executed agreements with my Home Fund to permit the transfer of contributions.
I   Elect   Do Not Elect to have my Welfare contributions remitted to my Home Fund.

I   Elect   Do Not Elect to have my Pension contributions remitted to my Home Fund.

I   Elect   Do Not Elect to have my Annuity contributions remitted to my Home Fund.
Iunderstand that the Cooperating Fund(s) will act solely as the agent of the noted Home Fund(s) and as such, I shall be subject to the eligibility rules of said Home Fund(s) upon the transfer of contributions. I hereby release (on behalf of myself as well as on behalf of anyone claiming through me) and further discharge the Cooperating Fund(s) and their Trustees of and from all claims, demands, actions, causes of actions or suits with respect to any contributions so transferred and for any benefits or credits which would have accrued or become payable to me has I not authorized this transfer of contribution. I further recognize that the transfer of contribution to the noted Home Fund(s) may or may not ultimately prove to be to the advantage of myself and/or my beneficiaries.
Signature:*

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Date Signed:*

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Date
THIS FORM HAS BEEN APPROVED BY THE IRON WORKER ADMINISTRATORS'S ROUND TABLE

Travel Service Dues

International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers LOCAL UNION NO. 28
Travel Service Dues (TSD) are $10.00 per week and must be kept current.

- TSD are accepted in the form of check, money order or credit/debit card. WE DO NOT ACCEPT CASH.

- Credit/debit card payments are accepted in-person at the Iron Workers Local 28 address listed below, OR by phone at (804)716-2081

- Checks and money orders shall be made payable to "Iron Workers Local 28" and must include your member number or social security number. Indicate the week(s) for which the TSD covers.

- If mailimng a paymnet:

1. Enclose a stamped, self-addressed envelope with your remittance in order to receive your receipt which must be presented to the Steward on the job to prove payment.

2. Send your remittance to:

Iron Workers Local 28

2831 Oak Lake Blvd.

Midlothian, VA 23112
WORKING ASSESSEMNT

Afour and one-half percent (4.5%) working assessment is deducted from wages for all ironworkers employed in the jurisdiction of Iron Workers Local Union #28.

I have read and understand the above statements.
Member Name (please print):*
Social Security Number:*
Member Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

IRON WORKERS

THIS FORM HAS BEEN APPROVED BY THE IRON WORKER ADMINISTRATORS'S ROUND TABLE

Travel Service Dues