Paid Time Off Benefit Request Form

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To receive PTO benefits, please complete form and submit it to the Plan office. Be sure to include a W-4
Form or taxes will be withheld on the basis of zero exemptions.
PAID TIME OFF BENEFIT REQUEST
UNDER THE TERMS AND CONDITIONS OF THE PAID TIME OFF (PTO) BENEFIT OF THE ELECTRICAL
CONSTRUCTION INDUSTRY VACATION HOLIDAY PLAN, THE ABOVE NAMED EMPLOYEE HAS A PTO
ACCOUNT BALANCE EQUAL TO $_____________ FOR WHICH HE/SHE CAN BE REIMBURSED BY THE
PLAN.
1. DISTRIBUTION AMOUNT. THE UNDERSIGNED EMPLOYEE HEREBY REQUESTS A PTO BENEFIT
DISTRIBUTION EQUAL TO _______ HOURS OF PTO (MUST BE IN 1-HOUR INCREMENTS, UNLESS NO
CONTRIBUTIONS HAVE BEEN MADE TO THE PLAN IN THE LAST 6 MONTHS). SPECIFY DATES OF
ABSENCE FROM WORK FOR WHICH YOU ARE REQUESTING PTO BENEFITS:
FROM:
TO:
2.
HOURLY WAGE. THE UNDERSIGNED EMPLOYEE’S HOURLY STRAIGHT TIME WAGE IS $_________.
3. EMPLOYER INFORMATION. IF YOU ARE EMPLOYED, YOUR EMPLOYER MUST SIGN THE FORM. INSERT
THE APPROPRIATE INFORMATION (OR, IF NOT EMPLOYED, CHECK THE BOX BELOW):
PRINT EMPLOYER NAME
EMPLOYER'S SIGNATURE
□ NOT EMPLOYED AT THIS TIME.
YOUR BENEFIT PAYMENT WILL BE DEPOSITED TO YOUR CHECKING OR SAVINGS ACCOUNT.
SIGNATURE. PLEASE SIGN THE FORM BELOW
4.
PRINT YOUR FULL NAME:
ADDRESS
EMPLOYEE’S SIGNATURE
CITY / STATE / ZIP

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