Return to forms Per Capita StatementYou may only submit payment for one quarter/month per submission. If you need to make multiple payments, please make multiple form submissions with separate payments.Name *Email *Date *Month *Day *Year *Union *Local # *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePer Capita Breakdown *By Hour per MonthBy Hour per QuarterCheck Off Status Local MinimumBy Members per QuarterQuarterly Payment Status MinimumSelect your payment/breakdown method to determine what additional information is needed to process your Per Capita statement.Check Off Status LocalsPer Capita Rate *USDHow many hours worked? *During what month? *Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDuring what quarter? *Select QuarterQ1Q2Q3Q4During which year? *Quarterly Payment StatusPer Capita Rate: $50.00 per working member for hours workedHow many working members? *During what quarter? *Select QuarterQ1Q2Q3Q4During which year? *Minimum payment: $50.00Per Capita Rate: $50.00 per monthTotal Owed$Paid per HoursTotal Owed$Members per QuarterTotal Owed$Local Minimum - No hours worked in QuarterTotal Owed$Quarterly Minimum - No hours worked in QuarterPer Capita Paid *USDProvide your payment amount here.Credit / Debit Card *Supporting Documentation *Drag and Drop (or) Choose FilesPer Capita payments are to be accompanied by supporting documentation. Please provide a digital copy here.Send Message Sidebar MenuAbout Trade Affiliates CIRCLE Associates News Forms Contact Calendar