NW Plumbers & Pipefitters Health Fund Vacation Fund Transfer Enrollment Form

NW Plumbers & Pipefitters Health Fund

Physical Address 7525 SE 24th Street, Suite 200, Mercer Island, WA 98040 - Mailing Address PO Box 34203, Seattle, WA 98124
Phone (866) 417-4240 - Fax (206) 695-0984 - Website www.nwplumberstrust.com

Administered by Welfare & Pension Administration Service, Inc.

ELECTRONIC VACATION FUND TRANSFER ENROLLMENT FORM

I hereby authorize the Northwest Plumbers & Pipefitters Health Fund to make deposits to my bank account. This authorization is to remain in full force and effect until the Administration Office receives written notice from me instructing otherwise. Fully completed forms with an attached voided check or savings deposit slip will need to be received by the 20th in order for the deposit to take place on the 15th of the following month. If a fully completed form and voided check or deposit slip is not received by the 20th, I understand a check will be mailed to my attention at my home address until the Administration Office has received all of the required information.

PLEASE PRINT ALL THE INFORMATION REQUESTED CLEARLY TO ENSURE THERE ARE NO DELAYS IN THE PROCESSING OF YOUR VACATION PAYMENTS
Name*
SSN*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
UA Local*
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Designated Vacation Bank Account
Name of Financial Institution*
Financial Institution Branch Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Financial Institution Customer Service Telephone Number *
Please enter a valid phone number.
Financial Institution ABA Routing Number*
Financial Institution Account Number*
Financial Institution Account Number
Financial Institution ABA Routing Number
PLEASE ATTACH A VOIDED CHECK OR SAVINGS DEPOSIT SLIP

Cancelof
Please Note: Failing to attach a deposit slip or voided check may result in a delay to your initial direct deposit
This designated Vacation Bank Account:*

IS a Joint AccountIS NOT a Joint Account
Account Type*

CheckingSavings
If this designated Vacation Bank Account is a Joint Account, the following persons are Joint Account holders and entitled to receive any information available on this account from the Trust Office.
Name*
SSN*
Name*
SSN*
Member's Signature

Clear
Member's Printed Name*
Date Signed*

MonthDayYear
Date
For additional information regarding your benefits, please visit our website at www.nwplumberstrust.com.
Should be Empty:

NW Plumbers & Pipefitters Health Fund

ELECTRONIC VACATION FUND TRANSFER ENROLLMENT FORM

Designated Vacation Bank Account