Brian Triplett’s Reciprocity Agreement

Submission Information

Participant Name

Brian Triplett

Social Security Number

315114872

I request and authorize that the Board of Trustees of the Local

841

Health and Welfare Fund to

transfer to my Home Health and Welfare Fund all contributions made on my behalf to its Fund hereafter and within six months prior to the date this authorization request is received by the Fund, unless and until this authorization is revoked in writing. In support of this request, I state as follows:

1. I am a member of IUOE Local No.

103

and my Union Registration No. is

4327049

2. My Home Health and Welfare Fund is

‏‏‎‎Mid central

3. I understand that, upon approval of my request to transfer, I cannot later request that any contributions which may be transferred to my Home Fund be transferred back to the transferring Fund.

4. I understand that, upon approval of my request to transfer contributions, my and my dependents’ eligibility for benefits and all other participant rights shall be determined exclusively by the terms of my Home Fund’s plan and rules, and not by the terms of the transferring Fund’s plan and rules.

5. By making this request, I waive and release, on behalf of myself and my dependents, any and all claims against both Funds and their fiduciaries relating to whether the transfer of contributions is in my or their best interests.

Street Address 3259 west water street	City Anderson	State Indiana	Zip Code 46011
Phone Number 7652747698
Date 20250402

Signature

Brian Triplett