IRONWORKERS 55 AUTHORIZATION OF CONTRIBUTIONS TRANSFER

RECIPROCAL AGREEMENT AUTHORIZATION OF CONTRIBUTIONS TRANSFER
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Last 4 of SSN
Date of Birth

MonthDayYear
Date
Home Local Number
Union Book Number
I hereby elect or do not elect as indicated below, to have contributions which are paid on my behalf to the following Funds, transferred to my Home Funds. 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.
ElectDo Not Elect
ElectDo Not Elect
ElectDo Not Elect
I understand 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 had I not authorized this transfer of contributions. I further recognize that the transfer of contributions to the noted Home Funds may or may not ultimately prove to be to the advantage of myself and/or my beneficiaries.
Date Signed

MonthDayYear
Date
Signature

Clear
NOTE: With respect to Annuity contributions, elective deferrals (i.e. any wage deductions you may have authorized in excess of the minimum employer contribution - currently $1.00 per hour) will not be reciprocated.
THIS FORM HAS BEEN APPROVED BY THE IRON WORKER ADMINISTRATOR'S ROUND TABLE
Should be Empty:

RECIPROCAL AGREEMENT AUTHORIZATION OF CONTRIBUTIONS TRANSFER

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