United Brotherhood of Carpenters and Joiners of America

FOR USE BY NY Locals 276, 277, 279, 290, 291 & Millwrights 1163

AUTHORIZATION FOR THE TRANSFER OF CONTRIBUTIONS

Please complete this form in its entirety (Parts A-D)

(A) Members Information:

 

(B)My Home Fund is the Fund within the jurisdiction of my Local Union. I want my contributions to go to my Home Funds. I am a participant in the Fund(s) listed below: Referred to as "Home" Fund(s):

Please check only the names of the HOME Fund(s) to which you want your contributions transferred to:

North Atlantic States Carpenters Health Benefits Fund 52 Stone Castle Rd, Rock Tavern, NY 12575

North Atlantic States Carpenters Pension Fund

52 Stone Castle Rd, Rock Tavern, NY 12575

C. Cooperating Outside Fund For the period beginning

I (will be working) (have worked) in an area covered by the

following Fund(s) Referred to as cooperating or "Outside" Fund(s):

Please list only the names of the cooperating OUTSIDE Fund(s):

Note: Since contribution rates vary from Fund to Fund, hours worked outside your "Home Fund" area may result in a reduction of credited hours.

D. Authorization/Signature I hereby elect, to the extent that the Trustees of the above cooperating Outside Fund(s) and the Trustees of my Home Fund(s) have agreed, through the execution of the International Reciprocal Agreement, to have contributions paid on my behalf to the cooperating Outside Fund(s) sent to my Home Fund upon the receipt of my "Authorization for the Transfer of Contributions" form. I understand this request for transfer of contributions must be filed within 60-days following commencement of my temporary employment within the jurisdiction of the cooperating Outside Fund(s This authorization and walver shall continue until revoked by me in writing, delivered to the Home Fund(s) and to the Outside Fund(s

I hereby release (on behalf of myself as well as on behalf of anyone claiming through me) and further discharge the cooperating Outside Fund(s) and its Trustees of and from all claims, demands, actions, causes of actions, and suits with respect to any contributions so transferred and for any benefits or credits which would have accrued or become payable to me or my beneficiaries had I not authorized this transfer of contributions. I understand that transferring contributions may negatively affect my eligibility.