Management Benets Fund (MBF)
Health and Fitness Reimbursement Program Claim Form
- please print -
I. CHECK ONE: (A separate form must be completed for each claimant.)
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 Unied Court System and retired
members) All active employees will be reimbursed through their regular paycheck.
ACCOUNT TYPE:
(CHECK ONLY ONE)
SAVINGS
CHECKING
PERSONS NAMED ON ACCOUNT:
(PRINT EXACTLY - INCLUDE TRUSTEE OR JOINT OWNER)
PERSON 1:______________________________________________
PERSON 2:______________________________________________
ABA NUMBER*
ACCOUNT NUMBER**
*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.)
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 benet.* The claimant
certies 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 benet. The claimant hereby certies that he or she has participated in a tness program for six
consecutive months. The claimant understands that the dollar value of this benet 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 benet, the Management Benets 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: STATE: ZIP CODE:
TELEPHONE NUMBER:
- -
DATE CURRENT MEMBERSHIP PURCHASED: ______/______/_________ TYPE OF MEMBERSHIP PURCHASED: INDIVIDUAL FAMILY**
TYPE OF MEMBERSHIP PURCHASED***:
MONTHLY: $__________________ SEMI-ANNUALLY: $__________________
ANNUALLY: $__________________ BIENNIAL: $__________________ TRIENNIAL: $__________________
** If your membership is a family contract, this payment will be prorated. *** Please attach a payment receipt or contract from health club.
VIII. PROGRAM VALIDATION: (To be signed by Facility Manager)
I hereby certify that the facility described above has a tness program and that the member attended the facility for six consecutive months.
FACILITY MANAGER’S SIGNATURE:______________________________________________________________________ DATE:______/______/______
H:\Forms\tness.indd 12/15
Please see the reverse side for Claim Filing Guidelines.
MM DD YYYY MM DD YYYY
MM DD YYYY
