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Get UFCW & Employers Trust Drug Trust Sick Leave Claim Form/Disability Extension Application 2011-2024

He undersigned, verify that the statements contained herein above under the heading “Employer Statement” are true and correct and I understand that these statements will be presented to the Trustees of UFCW Northern California Drug & Employers Health and Welfare Trust Fund used in support of the above named employee's Sick Leave claim. I understand that any false or fraudulent statement made herein may subject me to penalties as prescribed by law. Authorized EMPLOYER'S Name [Print]: ( Titl.

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