CEMENT & CONCRETE WORKERS DISTRICT COUNCIL
FRINGE BENEFIT FUNDS
214-38 42nd Avenue, 2nd Floor, Bayside, NY 11361
Phone: (718) 762.6133 * Fax: (718) 762-5144
EMPLOYER’S REMITTANCE AGREEMENT AND REPORT
THE CEMENT LEAGUE
JULY 1st 2025 TO JUNE 30th 2026
A B C
MAKE ONE CHECK PAYABLE TO:
CEMENT & CONCRETE FRINGE BENEFIT FUND
214-38 42nd Avenue, 2nd Floor,
Bayside, NY 11361
Tel: 718-762-6133 Fax: 718-762-5144
Amount Due – Part A: $__________ + Part B: $ _________ + Part C: $______________ = TOTAL DUE FROM CONTRACTOR $_______________________
ALL INFORMATION BELOW MUST BE FULLY PROVIDED WITH EACH REPORT: Print or Type
EMPLOYERS NAME: ___________________________________________________________________ TEL: ___________________
EMPLOYERS ADDRESS: ________________________________________________________ FAX: ___________________
JOB LOCATION: ____________________________________________________________________
NAME AND ADDRESS OF GENERAL CONTRACTOR: ________________________________________________________________________________
Report for week beginning: ______________________and ending: ____________________ Employers Federal ID Number:*_____________________
{PLEASE ENTER BOTH DATES – THANK YOU}
The Undersigned Employer hereby certifies that the information contained in this report and the attached schedule is true and correct, that the hours reported represent all hours worked by any cement and concrete worker in the employ of the named Employer for the period specified. The undersigned Employer hereby adopts and makes a part hereof the terms and conditions and the agreements printed on the reverse side hereof with the same force and effect as if fully set forth herein. The person signing this report on behalf of the Employer hereby consents and agrees to be personally bound by and to assume all of the terms and conditions, rights, liabilities and responsibilities of an employer in accordance with the provisions of the Collective Bargaining Agreement currently in force with the District Council of Cement and concrete Workers comprised of Locals Nos. 6-A, 18-A and 20, with the same force and effect as if fully set forth herein, and warrants and represents that he has authority to bind the Employer and the principals or members thereof. The Employer agrees to make all contributions in accordance therewith in the amount set forth on This report for each hour of employment performed within the trade and geographical jurisdiction of the District Council.
SIGNATURE OF CORPORATE OFFICER OR PARTNER___________________________________________DATE_____________________________
Print Name of Signer:_______________________________________________________________________Title______________________________
| SOCIAL SECURITY NUMBER | NAME | STRAIGHT HOURS | TIME & HALF HOURS | DOUBLE HOURS | TOTAL HOURS |