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.
Member Name*

First NameLast Name
Social Security #
Company*
Member Phone #*
Address*
Street, City, State & Zip Code
Todays 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
Date of Union Activity FROM:*

MonthDayYear
The start date from which your claiming loss time wages
Date of Union Activity TO:*

MonthDayYear
The end date from which your claiming loss time wages
Hours Claimed*
Wage Rate*
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Lost Time Wages/Earnings Claim Form