LOCAL UNION 373 HEALTH & WELFARE FUND
SUPPLEMENTAL UNEMPLOYMENT BENEFITS
P.O. Box 58 Mountainville, NY 10953 Telephone (845) 534-9765

Name _______________________________ SS# _____________________ L.U. # ________

Address _____________________________________________________________________
                street                          city                          state                           zip

Current Benefit: $150.00 per week for 13 weeks. Lay Off Date ____________   Period Of Claim _________________ To _________________ Verification Of Employment:                  ____ Unemployment Check Stubs(s)                                              ____ Union _____________________________________     ______________                                           (Business Manager or Agent must sign)                        Date ONLY ORIGINAL STATE UNEMPLOYMENT STUBS WILL BE ACCEPTED       I, the undersigned applicant,declare and represent to the Trustees of the L.U. 373 U.A. Health & Welfare Fund,that all the information set forth herein by me for this application is true and correct and is made for the express purpose as stated and furthermore, give permision the the Trustees to verify submitals as required. Date ________________________              Signed ______________________________________    I will pick my check up at the office                           Please mail my check to me TRUSTEE APPROVAL: ______________________________________      ______________________________________