	1375 Virginia Drive, Suite 102 Ft. Washington, PA 19034 Phone 215-542-8211

Don't Forget!

It's Your responsibility to update the Funds Office with any dependent changes - Birth of a child, Change in Marital Status, etc.

Census Card - use this form to add/delete dependents

International Union of Operating Engineers Benefit Funds
of Eastern Pennsylvania & Delaware

1375 Virginia Drive, Suite 102, Fort Washington, PA 19034

Phone: (215) 542-8211 www.iuoe542funds.com

Census Card

Name:
Last	M.I.		First
Social Security No.: (xxx-xx-xxxx)		Phone No.: (xxx-xxx-xxxx)

Address:
Street
City	State		Zip Code
Date of Birth: (mm/dd/yyyy)		Marital Status:
		Single Married DivorcedWidowed

A Marriage Certificate is required to add a spouse and

a Birth Certificate is required to add a Child.

Provide Name(s) of dependents below:

Signature* _______________________________ Date _______________

* Please Hand-sign this area and mail the form to the address above