Reciprocal Form

Reciprocal Transfer Authorization Form

Name(Required)

First Last

UBC Number (Format: U-8683-4454)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Local Union Number(Required)

Outside Local Union Number (local where work was performed outside your home local)(Required)

Outside Local Union City and State

Name of Outside Health Fund

Name of Outside Pension Fund

Name of Outside Annuity Fund

Contributions should be transferred to the home funds for (check all that apply below). These funds should be sent to: Southern Benefit Administrators, P.O. Box 1449, Goodlettsville, TN 37070-1449; Telephone: (800) 831-4914; Fax (615) 855-6105(Required)

Southern District UBC Health Trust

Carpenters Labor Management Pension Fund

Southern District UBC Defined Contribution Fund

By typing my name below, I hereby elect to have contributions paid on my behalf to the Cooperating Outside Fund(s) sent to my Home Fund(s). This authorization shall continue until revoked by me in writing and delivered to the Home Fund(s) and the Outside Fund(s).(Required)

Date(Required)