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: $100.00 per week for 10 weeks.

Lay Off Date ____________   Period Of Claim _________________ To _________________

Verification Of Employment:

                 ____ Unemployment Check Stubs(s)                                             

____ Union _____________________________________     ______________
                                           (Business Manager or Agent must sign)                        Date

Note: If you have exhausted your unemployment benefit, you must submit your last unemployment check stub to verify eligibility. You must also have the application signed by the Business Manager or Agent to verify that you are unemployed and ready, willing, and able to work.

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 permission 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:

______________________________________      ______________________________________