- Millwrights Local 1102

SUPPLEMENTAL PENSION
AUTHORIZATION REQUEST TO TRANSFER EMPLOYER CONTRIBUTIONS
UNDER RECIPROCITY AGREEMENTS
I,
, (print) am a member of or represented by a Local Union
which participates in the MILLWRIGHTS SUPPLEMENTAL PENSION FUND, and is
herein referred to as my "Home Fund". The address of my Home Fund is:
TIC CORP. . 6525 CENTURION DR. . LANSING, MI. 48917
I understand that there is or will be, a reciprocity agreement between my home fund and
Fund hereinafter referred to as "Out of Town"
Fund covering contributions.made to the latter named Fund for work performed by me
while working within the geographic area covered by it.
I authorize and request the transfer of employer contributions made in my behalf from the
"Out of Town" Fund to my Home Fund pursuant to the terms of the reciprocity
agreement. This authorization and request is to apply to the contributions made in my
behalf to the "Out of Town" Fund by the following employers:
and to contributions made in my behalf to said "Out of Town" Fund by any other
employers for whom I may work while this authorization and request is in force.
I hereby release any and all fiduciaries and all others involved in or connected with said
transfer from any and all liability which they might incur by reason of any loss or
damages resulting to me or my successors, heirs, or assigns by reason of or as a result of
said transfer. I specifically understand that the transfer of contributions hereby
authorized may not work to my best advantage.
This authorization and request shall remain in full force and effect unless I notify the
Trustees of the "Out of Town" Fund in writing of my desire to revoke it, in which case
this authorization and request shall terminate on the last day of the month in which such
notice is received by the Trustees of the "Out of Town" Fund.
Signature
Social Security Number
Address
Local Union Number
City, State, Zip'
Date of Birth
Date signed
PENSION
AUTHOR I ZXT I ON AND REQUEST TO TRAN87EB EMI-LOYRR CONTRIBUTIONS
UNDSR RECIPROCITY
I,
_______
; _,,..... ,( print) , am a member or or represented by a Local
Union Which participates in the . Michigan Carpenters Pension Fund ____ Fund, and
is hereinafter referred to as my "Home Fund," The address of this FunJ is
6525 Centurion Drive Lansing, Michigan 4891 7-9275
_
.
I understand that there i ± , or will be, a reciprocity agreement between my
Home Fund and _
'.________ __________________
Fund hereinafter referred to as "Out-of-Town Fund" covering contributions
made to the latter named Fund for work performed by me while working within
the geographic area covered by it.
I hereby authorize and request the transfer of employer contributions made in
my behalf from the Out-of-Town Fund to my Home Fund pursuant to the terms of
the reciprocity agreement. This authorization and request is to apply to the
contributions made in my behalf to the Out-of-Town Fund by the following
employers I
and to contributions made in my behalf to said Out-of-Town fund by any '~>ther
employers for whom I may work while this authorization 'and request iii in
force.
I hereby release any and all fiduciaries and ull others involved in or
connected with said transfer from any and all liability which they might
incur by reason of any loss or damages resulting to me or my succeasors,
heirs or assigns by reason of or as a result of said transfer,
I
specifically understand that the transfer of contributions hereby authorized
may not work to my best advantage.
This authorization and request shall remain in lull force and effect unless
I notify the Trustees of the Out-of-Town Fund in writing of. my deeitc to
revoke it, in whioh case this authorization and request shall terminate on
the last day of the month in which a,uch notice is received by the Trustees of
the Out-of-Town Fund.
Signature
Social Security Number
Address (Street)
Local Union Number
(City, State, Zip)
Date of birth
Date
HEALTH AND HRt-FARB
AUTHORIZATION AND UEQUBBT TO .TRANSFER EMPLOxi.'it CONTRIBUTIONS
UNDER RECIPROCITY ACIREBMEN'i li
I,
(print), am a member of or r«!j>r««entod by a Lucal
Union Which participates in the Millwrights Local 1102 Health Care
Fund, and
ifl hereinafter referred to «.;e my "Home i-unu." me uuuiess oi" this Fund iu
6525 Centurion Drive, Lansing, Michigan 48917
I understand that there ie, or will bo, a reciprocity agreement between my
Home Fund and
_~—
Fund hereinafter referred to as "Out-of-Town Fund" covering contributions
made to the latter named Fund for work performed by ;ue while working within
the geographic area covered by it.
I hereby authorize and recjueot the transfer of emplo, u.c contributions made in
jny behalf from the Out-of-Town Fund to my Home Fund pursuant to the terms of
the reciprocity agreement. This authorization and r&tjuest i.y to apply to li.e
contributions made in my behalf to the Out*-of-Town Fund by the following
employers:
and to contributions made in wy behalf to said out-*,'I-Town Fund by any other
employers for whom I may work while this authorisation and request is in
forca*
I hereby release any and all fiduciaries and all jthers involved in -.aconnected
with said transfer from any and all liability which they mi<ji'jt
in1 ur by reason of any loss or damages resulting to we or my tmucseseoru,
heirs or assigns by reasoa of or as a result of said transfer.
l
specifically understand that the transfer of contributions hereby authored
may not work to my best advantage.
This authorization and request shall remain in full force and effect unlcuu
I notify the Trustees of the Out-of-Town Fund in writing i»T .my desire Lu
revoke it, in which case thifc authorization and request, shall terminate un
tho last day of the month in which sucl; notice is received by Lhe Trustees o£
the Out-of-Town Fund.
Signature
Social Security Number
Address (Street)
Local Union Number
Address (City, State, Zip)
Date of Dirlh
Date