|Current Benefit: $100.00 per week for 10 weeks.|
Lay Off Date ____________ Period Of Claim _________________ To _________________
Verification Of Employment:
____ Unemployment Check Stubs(s)
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.
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 ______________________________________