Management Benefits Fund (Mbf) Health And Fitness Reimbursement Program Claim Form

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Management Benefits Fund (MBF)

Health and Fitness Reimbursement Program Claim Form

please print

I. CHECK ONE: (A separate form must be completed for each claimant.)

Reset Form

MBF MEMBER

MBF MEMBER SPOUSE/DOMESTIC PARTNER



II. MBF MEMBER INFORMATION:

SOCIAL SECURITY #:

AGENCY NAME:

LAST NAME:

FIRST NAME:

M.I.:

ADDRESS:

CITY:

STATE:

ZIP CODE:

WORK TELEPHONE NUMBER:

HOME TELEPHONE NUMBER:

III. SPOUSE/DOMESTIC PARTNER INFORMATION: (To be completed only if claimant is MBF member’s spouse/domestic partner)

LAST NAME:

FIRST NAME:

M.I.:

IV. DIRECT DEPOSIT VIA PERSONAL ACCOUNT INFORMATION: (Only available to employees of the Unified Court System and retired

members) All active employees will be reimbursed through their regular paycheck.

ACCOUNT TYPE:

PERSONS NAMED ON ACCOUNT:

ABA NUMBER*

(CHECK ONLY ONE)

(PRINT EXACTLY - INCLUDE TRUSTEE OR JOINT OWNER)

SAVINGS



PERSON 1:______________________________________________

ACCOUNT NUMBER**

CHECKING



PERSON 2:______________________________________________

*ABA BANK NUMBER: CHECKING ACCOUNTS - THE ABA NUMBER IS THE FIRST NINE (9) NUMBERS PRIOR TO THE ACCOUNT NUMBER AT THE BOTTOM LEFT CORNER OF THE CHECK.

SAVINGS ACCOUNTS - CONTACT YOUR BANK FOR THE ABA NUMBER, IF NOT KNOWN. **ACCOUNT NUMBER: SEE CHECK, PASSBOOK, OR ACCOUNT STATEMENT FOR ACCOUNT NUMBER.

V. CLAIM PERIOD (Please indicate a six (6) month claim period only.)

YYYY

BEGIN DATE: ______/______/_________

END DATE: ______/______/_________

(End date must not exceed two (2) years from date of claim submission.)

VI. SIGNATURE

By signing this form, the claimant hereby acknowledes that MBF has not given any medical advice nor has recommended participation in this benefit.* The claimant

certifies that he or she has no current medical condition that would prohibit participation in an exercise program. The claimant further acknowledges that MBF bears no

liability resulting from any injuries or damages arising from use of this benefit. The claimant hereby certifies that he or she has participated in a fitness program for six

consecutive months. The claimant understands that the dollar value of this benefit will be included as taxable income to the MBF member.

The claimant hereby authorizes MBF to deposit his or her Health and Fitness reimbursement directly into his or her checking or savings account as requested, if

applicable. The claimant also grants authorization for the reversal of a credit to the account in the event the credit was made in error. The claimant understands that,

under the “National Automated Clearing House Association” operating guidelines and rules, MBF can only reverse the amount of the incorrect direct deposit. The

claimant must provide direct deposit information for each claim submitted.

MEMBER’S SIGNATURE:_________________________________________________________________________________ DATE:______/______/______

Required

SPOUSE’S/DOMESTIC PARTNER’S SIGNATURE:____________________________________________________________

DATE:______/______/______

Spouse’s/domestic partner’s claim cannot be processed without member’s signature.

* Prior to participating in this benefit, the Management Benefits Fund recommends that you consult with your own physician.

VII. HEALTH CLUB/FITNESS FACILITY AND MEMBERSHIP INFORMATION: (Please print.)

FACILITY NAME:

NAME OF FACILITY MANAGER

ADDRESS:

CITY: