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INTERNATIONAL UNION OF PAINTERS AND ALLIED TRADES
INDUSTRY PENSION PLAN
7234 Parkway Drive
Hanover, MD 21076
Phone (800) 554-2479 / Fax (866) 656-4160 - Email: pension@iupat.org


Section 1: Applicant Information (Complete All Fields)
Enter Street Address
Enter Date of Birth
Enter City
Select State
Enter Zip Code
SSN without hyphens
Home Phone Number
Cell Phone Number
Email Address
Enter the desired Month and
Year for start of Retirement Pay
(Date must be within 6 months):
Month
Year
Mother's Maiden Name
Relationship to the Participant with Pension Plan Benefits (Select One):
Section 2: Participant Information (The Person who worked and has Pension Plan Benefits)
SSN without hyphens
Enter Date of Birth
Last District Council or Local Union
Marital Status
Home Phone Number
Cell Phone Number
Current or last IUPAT Plan / Company worked (or intended last date)
Date Last Worked
Employer
City, State
Section 3: Social Security (Level Income) Pension Option
Please complete the following with the age you expect to begin receiving Social Security benefits and the estimated amount you are going to receive. You must apply for your Social Security three months in advance of your leveling date to ensure you receive your Social Security benefits concurrently with your reduced Pension benefit. (The Fund can process your application without this information but you will not receive information on the Social Security Level Income options on page 33 of your Summary Plan Description booklet and you will not be able to elect that form of payment.)
Age
Benefit Amount
Section 4: Disability Pension
If you are applying for retirement based on disability, please complete this section and attach or send your Disability Award from the Social Security Administration Fund as soon as you receive it. Please see page 25 through 28 of your Summary Plan Description Booklet.
Section 5: Spouse Information
(If you have no current of former spouse who may be entitled to part of your pension benefits, mark the checkbox 'None' and complete Section 7 below.)
Address of Spouse (If different from applicant)
Street Address
City
Select State
Zip Code
Date of Birth
SSN without hyphens
Spouses Marital Status
Section 6: Beneficiary Information
(Please complete the following section if you want information on a Joint and Survivor benefit with someone other than your current spouse or if you are NOT electing a Joint and Survivor Benefit. See page 34 of your Summary Plan Description for more information)
Address of Spouse (If different from applicant)
Street Address
City
Select State
Zip Code
Date of Birth
SSN without hyphens
Relationship to Plan participant
Section 7: Complete the following if you are single (NOT married). - CHECK ONE
YOU MUST HAVE THIS SECTION NOTARIZED IF YOU CLAIM THAT YOU ARE NOT MARRIED.

Subscribed and sworn before me on _________________________ (date)
Applicants Signature ____________________________________________
NOTARY PUBLIC ____________________________________________________
Section 8: Applicant's Statement
Pursuant to federal law, I state under penalty of perjury that the foregoing is true to the best of my knowledge, information and belief. I have read and understand the previous statements and all answers and information provided on this application. I understand that a false statement may disqualify me for pension benefits and/or subject me to sanctions under Federal or State Law. I also understand that the Fund has the right to adjust my benefits and recover any payment made to me because of a false or inaccurate statement, even if I did not know it was untrue.

Date ________________________________
Applicant's Signature _____________________________________________________
OPTIONAL: Receive Text/SMS Pension Application Status Messages
To receive text/sms status updates on your Pension Application, provide your cell/mobile number below. (Cellular messaging rates may apply)
Mobile/Cell Phone Number for SMS messages

Please review and submit your application (only submit one application, multiple submissions will delay processing). Once submitted a printable version of your application will be generated that you will need to sign and if required have notarized (see section 7); a second page will be generated that will provide instructions for mailing this signed hard-copy form to the IUPAT Pension Fund along with copies of any required supporting documents (this will be listed for you as a checklist). If you have questions or need assistance, contact the IUPAT Pension Fund at (800)544-2479.