Lost Time Wages form Teamsters 350

Lost Time Wages/Earnings Claim Form

THIS FORM IS TO BE COMPLETED BY THE MEMBER
ONLY COMPLETE IF NOT PAID LOST TIME WAGES BY EMPLOYER; to include straight time, sick time, or vacation time.
Name*

First NameLast Name
Social Security #
Company
Phone #
Address
Street, City, State & Zip Code
Date
The Company DID NOT pay me Lost Time Wages either in the form of vacation/sick/straight time hours for negotiations and/or attending activities on behalf of the Local Union:

Check here if this applies
Answer the following questions about your involvement in union activities and the period for which you are claiming loss time wages/earnings.
Union Activity
Date of Union Activity
Hours Claimed
Wage Rate
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Lost Time Wages/Earnings Claim Form