Fillable Paid Time Off Benefit Request printable pdf download

Paid Time Off Benefit Request

Download a blank fillable Paid Time Off Benefit Request in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Paid Time Off Benefit Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

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:

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.

4. DELIVERY INFORMATION AND SIGNATURE. PLEASE PROVIDE DELIVERY INFORMATION AND SIGN THE

FORM BELOW.

MAIL

□

PLEASE

MY CHECK TO ME

□

UNION

I WILL PICK UP MY CHECK AT LOCAL

#494 (103rd St.)

PLAN

□

I WILL PICK UP MY CHECK AT THE

OFFICE

IF YOU HAVE SUBMITTED A DIRECT DEPOSIT AUTHORIZATION FORM, YOUR BENEFIT PAYMENT WILL BE DEPOSITED

TO YOUR CHECKING OR SAVINGS ACCOUNT.

PRINT YOUR FULL NAME:

ADDRESS

EMPLOYEE’S SIGNATURE

CITY / STATE / ZIP

Paid Time Off Benefit Request

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