• English Quick guide on how to complete notice:

    1. Enter your Full Name: First Name Last Name
    2. Enter Last Four of SSN
    3. Enter your phone number
    4. Enter your Email address (If you have an Email address)
    5. Sign your name (You can click “clear” button and sign again)
    6. Click “SUMBIT” Button

 

  • If shows up “One or more fields have an error. Please check and try again.”, please double check and click “SUMBIT” button again!

  • Success message

  • 195 form

    1. $17+$4.09 FBA+ $0.79 PTO (Sick+Vac)

    EMPLOYEE INFORMATION

    Signature

    EMPLOYER SECTION ONLY











    *If wage supplements are paid as a single payment owed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

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