TEMPORARY APPLICATION FOR SUB PLAN BENEFITS
(April, May, and June 2020)
Southern California IBEW-NECA Supplemental Unemployment Benefit Trust Fund
Local 11 Inside Wiremen, Intelligent
Transportation, and Inspectors
6023 Garfield Avenue, Commerce, CA90040
(323) 221-5861 (800) 824-6935 Fax (323) 726-3520
In accordance with the provisions of the Plan, I hereby apply for benefits under the Supplemental
Unemployment Benefit Trust Fund (SUB).
Section 1 │ Personal Information
Name
Social Security # Phone No.
Street Address
City State Zip Code
Section 2 │ Work Status Information
1.
Last Date Worked
Last Employer
2.
Reason for No Longer Working
☐Terminated/Laid Off (attach copy of proof) ☐Temporary Furlough (attach copy of proof)
3.
A. ☐Journeymen (attach copy of out of workbook registration verification)
B. ☐Apprentices (attach copy of ETI layoff notice)
4. Date Applied for State of California Unemployment Benefits
(attach copy of proof)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct and that this declaration is executed on at ,
California.
Signature
You are responsible for paying any applicable federal, state and local taxes incurred as a result of the
payment of benefits under the Plan. Supplemental Unemployment Benefits are subject to income tax
withholding and other tax withholding by the Plan to the extent required by the IRS code or other applicable
law. You should contact your tax adviser for more information.
(Office use only)
SOUTHERN CALIFORNIA IBEW-NECA SUB TRUST FUND
Begin Date End Date
Distribution: File
IBEW Local 11
LA NECA
PLEASE DO NOT WRITE BELOW THIS AREA
