GREATER GREEN BAY YMCA - THE EMPLOYEE INFORMATION PACKET FOR HEALTH AND DAYCARE FLEXIBLE SPENDING PLANS

 
GREATER GREEN BAY YMCA
             PRESENTS

THE EMPLOYEE INFORMATION PACKET FOR
        HEALTH AND DAYCARE
      FLEXIBLE SPENDING PLANS

             P.O. Box 5546
             De Pere, WI 54115-5546
             Phone: (920) 339-0351
             Fax #’s: (920) 339-0038 or (920) 339-5736
             www.benefitadvantage.com
TABLE OF CONTENTS

Benefits offered ……………………………………………………………………………………… Pg. 3

How the plan works ………………………………………………………………………………….. Pg. 4

Enrollment, Incurring Expenses, Requesting Reimbursement ………………………………………. Pg. 4

Claim submission and Inquiry ………………………………..…………………………………….…Pg. 5

What types of expenses are eligible for reimbursement? ……………………………………………..Pg. 6

What types of expenses are not eligible for reimbursement? …………………………………………Pg. 7

Frequently asked questions …………………………………………………………………………..Pg.8-9

Plan Information Sheet ………………………….……………………………………………………Pg.10

CONFIDENTIALITY STATEMENT

By enrolling in the Flexible Spending Account (FSA) and submitting FSA claims, you specifically authorize the Plan,
Benefit Advantage Inc., and their respective agents, employees, sub-contractors, and assigns to use your personal
information in their possession to administer the Plan (including the evaluation of eligibility for reimbursement under
the Plan) to detect or prevent fraud or misrepresentation and to further disclose such information as is reasonably
required for such purposes. You further authorize any provider, insurer, or other entity to release any health or
treatment information for the purposes of administering the Plan (including determining eligibility for Plan benefits) or
detecting or preventing fraud or misrepresentation and waive and release any claims related to the use, disclosure or
release of such information so long as the information is used in furtherance of Plan administration or processing or
evaluating a claim for benefits under the plan. This authorization does not and is not intended to in any way limit any
right the Plan or Benefit Advantage Inc., or their respective agents, employees, subcontractor, and assigns may have
under applicable state or federal law or regulation regarding the use of such information.
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

The IRS states that an eligible dependent for the purpose of a Dependent Care reimbursement Plan is a child under
13 years old and living with you. An eligible dependent, regardless of age, may also include your mentally or
physically impaired spouse/dependent/child that is living with you regardless of age and incapable of caring for him
or herself.

To be eligible to participate in this account all of the following must apply:

        1. The expenses must be necessary to allow you and your spouse to work, seek employment, or attend
           school full time.
        2. These providers must declare the funds you pay them as income on their tax returns.
               A. Eligible providers include:
                              Child care centers
                              Family day care providers
                              Babysitters
                              Nursery schools *this does not include tuition for kindergarten
                              Caregivers for disabled dependent or spouse who lives with you

 The IRS states the annual maximum amount a family may withhold in a dependent care plan is the lesser of
$5,000 per family, or you or your spouse's income. A single parent is eligible for this program with the above
limitations.

If you and your working spouse have dependent care accounts with your employers, the maximum combined
contribution is $5,000. Married individuals filing separate tax returns can each claim a maximum of $2,500
through a flexible spending account.

If you are married and your spouse is a full-time student or unable to care for himself, or herself, you may claim
$2,400 if you have one (1) dependent, or $4,800 if you have more than one dependent.

                           HEALTH CARE FLEXIBLE SPENDING ACCOUNT

The Health Flexible Spending Account (FSA) gives you the benefit of allocating money pre-tax to reimburse you
for out-of-pocket medical expenses for you and your dependents during a Plan year. Dependents include your
spouse, children residing with you, or a parent for whom you claim on your taxes as a dependent. You do not need
to participate in your Company's group insurance plan in order to participate in the Health Care Flexible Spending
Account.

Page 6 identifies some of the common medical and health-related expenses that the Internal Revenue Service
considers to be eligible for reimbursement through a Health FSA. These expenses are only eligible for
reimbursement provided that you have not been reimbursed for them by another source. Expenses incurred for
cosmetic purposes are not eligible for reimbursement.

Eligible expenses include, but are not limited to, your medical and dental deductibles, co-pays, vision and hearing
care, expenses in excess of "usual, reasonable and customary" charges and other health care costs not covered
under your or your spouse's insurance plan.
HOW IT ALL WORKS

Enrollment

Prior to the beginning of each plan year, you may elect the amount that you want to contribute to the plan.
Throughout the plan year equal payroll deductions will be taken from your pay before Federal, State, and
Social Security taxes are assessed. The deduction will then be deposited into your Flexible Spending
Account(s).
You must indicate the annual amount you would like to contribute, sign, and date your election form by
the deadline set by your employer. Please review the Plan Information included for specific Plan dates.

Dependent Care Flexible Spending-
 Your election may not exceed $5000.00 per family, per year.

Health Care Flexible Spending-
 Your election limit is set by your employer. Please refer to the enclosed Plan Information.

Once the Plan year begins, your election is irrevocable and cannot be changed unless there is a qualifying
event. Please refer to your SPD for further information.

Incurring Expenses

As you incur qualified Medical expenses, you will complete and send to Benefit Advantage a
reimbursement request form itemizing your expenses with supporting documentation. The expenses must
be for services incurred during the current plan year. You will have a run off period after the close of the
plan year to submit your requests for expenses incurred during the previous plan year. Please refer to your
Summary Plan Description (SPD) for limits on your plan.

 If your employment terminates during the plan year, you may only submit claims incurred up to your
termination date. After you terminate, you will have a submission period to submit claims, please refer to
your SPD for details.

Documenting your expenses
All documentation included with your claim form must have the following listed:
Date of Service, Description of Service, Patient Name, Provider Name and Patient Responsibility. Credit
Card receipts, copies of Cancelled Checks, and Statements from your provider that list codes for a
description are not considered valid documentation. Cash register receipts for Over the Counter items
must also list a description of the item purchased.

Reimbursements
All qualified claim requests will be processed and issued to you within 5 business days. A Direct Deposit
payment will be issued directly to the participant and it is the responsibility of the participant to forward
these funds on to their provider if necessary. Benefit Advantage will not send any funds to the provider.

Dependent Care                Daycare expenses are reimbursed up to the cash
 Pays Up To                    balance in your account.
 Cash Balance                  Unpaid claims are reimbursed as additional funds
                               are credited to your account via payroll deductions.

Health Care                   You may be reimbursed your entire annual health
 Pays Up To                    care election at any time during the plan year after you have incurred
 Annual Election               the expense.
CLAIM SUBMISSION AND INQUIRY

You can review your account online at www.benefitadvantage.com

Online Account Status

To obtain your flexible spending account balance or claim status information:
    Select Customer Login
    Employee ID = Participants Social Security Number (without spaces or dashes)
    Enter Pin code= Last four digits of Social Security Number
       *This can be changed per the request of the participant to another four digit number*
    You will be prompted to add your e-mail address.
    After first log in, User ID will be your e-mail address, and password will remain the same.

Reimbursement Claim Forms

To access the claim form on our website:
    Select Forms
    Select Flexible Spending Account
    Select the appropriate form, Medical Claim form, Dependent Care Claim form, or
       Recurring Orthodontia claim form
    Print the selected claim form, complete, then mail or fax to Benefit Advantage.

                                       CLAIMS SUBMISSION

Mailing Address: Benefit Advantage
                 P.O. Box 5546
                 De Pere, WI 54115-5546

Fax Numbers:  (920) 339-0038 or (920) 339-5736
Phone Number: (920) 339-0351
ELIGIBLE EXPENSES
The following list identifies some of the common medical and health-related expenses the Internal Revenue Service
considers to eligible for reimbursement through a Health FSA, provided you have not been reimbursed for them through
any other benefit coverage. Expenses incurred for cosmetic purposes are not eligible.

The recently enacted Patient Protection and Affordable Care Act of 2010 changes the rules for the purchase of over-the-
counter (OTC) products using Flexible Spending Account (FSA) effective January 1, 2011.

**Over-the-Counter medicines will not be eligible for reimbursement without a prescription after 1/1/2011.

   Acupuncture                                                   Itemized Hospital bills
   Alcoholism treatment                                          Laboratory fees
   Ambulance hire                                                Childbirth Classes
   Artificial limbs                                              Lasik vision surgery
   Artificial teeth                                              Lodging for medical care($50 per person per night)
   Aspirin**                                                     Mileage for medical care
   Bandages                                                      Nurse’s fees
   Birth control pills                                           Obstetrical expenses
   Braces                                                        Operations
   Braille books and magazines                                   Orthodontic treatment
   Car controls for the disabled                                 Orthopedic shoes
   Care for the mentally disabled                                Over the Counter Medicines**
   Chiropractors                                                 Oxygen
   Co-pay                                                        Physician’s fees
   Contact lenses and supplies                                   Prescription drugs
   Crutches                                                      Psychiatric care
   Dental fees                                                   Routine physical
   Dermatologist                                                 Smoking cessation program/related drugs
   Diagnostic fees                                               Sterilization fees
   Drug addiction therapy                                        Surgical fees
   Eyeglasses, including exam fee                                Telephone for the hearing impaired
   Fees for practical nurse                                      Television display for hearing impaired
   First Aid Kits                                                Psychotherapy
   Guide dog and its upkeep                                      Tuition at special schools for disabled
   Health insurance deductibles                                  Wheelchair
   Hearing devices and batteries                                 Wigs - for medical reasons
   Hypnosis for treatment of an illness                          X-rays
   Insulin and diabetic supplies

    Note: This is not an all-inclusive list. If you have questions regarding an expense, please call Benefit
   Advantage at (800) 686-6829 and speak with a representative.
INELIGIBLE EXPENSES

The IRS does not allow the following expenses to be reimbursed under the Health FSA. Expenses to promote general
health are not eligible expenses.

The recently enacted Patient Protection and Affordable Care Act of 2010 changes the rules for the purchase of over-the-
counter (OTC) products using Flexible Spending Account (FSA) effective January 1, 2011.

**Over-the-Counter medicines will not be eligible for reimbursement without a prescription after 1/1/2011.

Breast Feeding Classes                                          Massage Therapy*
Breast Pumps                                                    Maternity Clothes
Bonding *                                                       Over-the-Counter Medicines**
Canceled Appointment Fees                                       Personal Trainer
Cosmetic Surgery/Procedures                                     Prescription Drug Discount
Dancing Lessons                                                 Program Premiums
Diaper Service                                                  Special Foods
Discounts/Write-offs                                            Student Health Fee
Electrolysis                                                    Swimming Lessons
Exercise Equipment*                                             Teeth Whitening/Bleaching
Hair Loss Medications*                                          Toiletries, Toothpaste, Etc.
Hair Transplant                                                 Veneers
Illegal Operation or Treatment                                  Vision or Health Discount Program Premiums
Insurance Premium Interest Charge                               Vitamins/Supplements
Insurance Premiums                                              Weight Loss Programs &/or Drugs
      Marriage Counseling

      * Eligible only with Doctor’s certification identifying the medical condition, prescribed
      treatment, and duration of treatment. Amount reimbursed may be the difference of a common
      item and the special item.

       Note: This is not an all-inclusive list. If you have questions regarding an expense, please
      call Benefit Advantage at (800) 686-6829 and speak with a representative.
FREQUENTLY ASKED QUESTIONS
Q1   What are the advantages to this new Flexible                   Q6   How do I get reimbursed for Health Care expenses?
     Benefit Plan, and how will it affect me?                       A6   To request reimbursement from Benefit Advantage you must
A1   A Flexible Benefit Plan is another benefit Plan that allows         complete a claim form, and include a copy of the itemized
     you to have certain expenses deducted from your paycheck            statement for the services that were provided. Please note that
     before taxes, thus reducing the amount of taxes you pay,            we cannot accept credit card bills/receipts or canceled checks as
     giving you more spendable income for the year. You have             proof of service.
     two choices. They are:
     1. Health Care Reimbursement Account (i.e.:                         If you know your Orthodontic expenses will remain at the same
         medical, dental and vision expenses.)                           dollar amount for the calendar year, you are encouraged to use a
     2. Dependent Care Reimbursement Account                             Recurring Ortho Care Reimbursement Request Form. This
         (i.e.: daycare, babysitter*)                                    allows you to submit the reimbursement form only once to
     *Babysitter must report income                                      Benefit Advantage along with your Ortho Contract, and we will
                                                                         release a claim on your behalf every month. You must notify
                                                                         us if the provider or amount of your claim changes. This
Q2   Do I have to participate in all choices?                            form is also available in your Human Resource Department.
A2   No. Those who do not have children, a spouse                        The Recurring Claim Form does not carry over into the
     or parents requiring daycare will not be interested in the          next plan year. At re-enrollment time, you must fill out a new
     Dependent Care Account.                                             Recurring Form and submit it to Benefit Advantage.

Q3   Is this an automatic election or do I need to sign a form?     Q7   I've been deducting medical and dental expenses on my
A3   Every employee must complete a form(s) to enroll. Return            income taxes. Can this continue if I enroll in the
     your completed form(s) to the Human Resource Department             Flexible Benefit Plan?
     before the last day of open enrollment.                        A7   Currently you can deduct on your income tax return only the
                                                                         portion of your expenses that exceeds 7-1/2% of your household
Q4   Can I change my amount or get into the plan after the               income. The Flexible Benefit Plan gives you immediate first
     beginning of the plan year?                                         dollar savings on Federal, State (except in PA and NJ) and
A4   You may change your election during the plan year only if           FICA taxes. You may not claim expenses reimbursed from
     you have a change in family status, such as marriage,               your flexible spending plan on your tax return.
     divorce, death, birth, or adoption. Otherwise, you will have
     to wait until the next enrollment period. The change you       Q8   If I allocate $100 into my Health Care Expense Account,
     make must be consistent with the qualifying event. If you           and I incur only $80 of charges for the calendar year, what
     have any of the above qualifying events, you must contact           happens to the $20?
     your Human Resource Department within 30 days of the           A8   The IRS states that if you do not have expenses that equal the
     event.                                                              money you have set aside on a pre-tax basis, you lose the
                                                                         amount remaining in your account at the end of the year. This
Q5   Who determines what is an eligible expense that I can               is why we ask you to be cautious with your election. Your
     claim reimbursement for?                                            employer cannot return forfeited amounts directly to you.
A5   The IRS formulates the guidelines for the Health FSA
     Accounts and determines what is eligible. A list of some
     eligible expenses is included within this publication.
FREQUENTLY ASKED QUESTIONS,
                                 CONTINUED
Q9    What forms do I need to send to Benefit Advantage for               Q13   How does participation in the Flexible Benefit Plan affect
      reimbursement for dependent care expenses?                                information on my W-2 form?
A9    You need to complete a Day Care Reimbursement Request Form          A13   Your taxable income on the W-2 form will be reduced by
      with receipts showing amount of payment, date of service                  contributions to any portion of the Flexible Benefit Plan. Funds
      provided, Tax I.D. or Social Security number of your dependent            contributed to the Dependent Care Account will be shown in a
      care provider. If your dependent care provider does not issue             separate location on the W-2 form as a non-taxable item.
      receipts, a signature line is provided on the reimbursement form
      for their signature and Tax I.D. or Social Security number.         Q14   If I terminate employment, what happens to the money I
                                                                                have allocated to the Plan?
      If you know your monthly dependent care expense will remain at      A14   You will have a grace period following termination to submit
      the same dollar amount for the calendar year, you are encouraged          claims for reimbursement of expenses that were incurred on
      to use the Recurring Daycare Reimbursement Request Form. This             your termination date or prior. Any unused amount after the
      form allows you to submit the reimbursement form only once to             run off period will be forfeited if you terminate with a positive
      Benefit Advantage, and we will see that you are reimbursed                balance. You may be eligible to elect to continue your
      accordingly. You must notify us if the provider or amount of              participation in the Health FSA with COBRA.
      your claim changes. Additional forms are available in your
      Human Resource Department. The Recurring Claim Form does            Q15   Once I file an eligible medical, dental, or dependent care
      not carry over into the next plan year. At re-enrollment time,            expense, how long do I have to wait until Benefit Advantage
      you must fill out a new Recurring Form and submit it to Benefit           reimburses me.
      Advantage. Recurring claims are released at the end of the first    A15   Benefit Advantage sends out reimbursements on a daily basis
      full week of each month.                                                  and guarantees a 5 business-day turnaround on claims. You can
                                                                                review your claim status at www.benefitadvantage.com.
Q10   My mother-in-law baby-sits for my two children. She doesn't
      claim this income on her income taxes. Can I participate in         Q16   Will I receive a report showing me how much money I have
      the dependent care account?                                               used from the Plan?
A10   No. You may participate in the Dependent Care Reimbursement         A16   You may view your account status at anytime at
      Account only if the daycare provider claims the amount you pay            www.benefitadvantage.com . On our website you can review
      them on their income taxes.                                               your claim history, payment history and current balance.
                                                                                Benefit Advantage also sends a statement the last quarter of the
Q11   I over-calculated my dependent care expenses. Can I get the               Plan Year to employees who still have money in their accounts.
      leftover money in my account at the end of the year?                      This statement is a reminder to use your money so you do not
A11   No. Money left in your dependent care account must be forfeited           forfeit any left over funds.
      according to IRS regulations. (See question 8)
                                                                          Q17   Who do I contact with questions or concerns on the Flexible
Q12   I am currently using the Child Care Credit on my income tax               Benefit Plan?
      return. Can I use the Flexible Benefit Plan also? Which gives       A17   Call Benefit Advantage at (920) 339-0351 or (800) 686-6829.
      me greater savings?
A12   It is possible to use both; however, expenses in the Dependent
      Care Account reduce expenses allowed by the Child Care Credit
      dollar for dollar.
      The Child Care Credit on your income tax return allows expenses
      up to $3,000 for one child and $6,000 for two or more children.
      This is a credit of taxes owed when your tax return is filed. The
      Dependent Care Account allows immediate elimination of
      Federal, State (except PA and NJ) and FICA taxes on expenses up
      to $5,000 regardless of the number of children.
      Please contact the individual who prepares your income tax return
      for assistance in determining which program provides the greatest
      savings for you.
GREATER GREEN BAY YMCA
                                       Plan Information
                                  Flexible Spending Accounts
Would you like to reduce your out-of-pocket medical, dental, vision and daycare expenses by saving tax dollars?
If you, or your family, incur qualified expenses during a plan year, you can enjoy tax savings simply by changing
the way you pay for health care and daycare expenses.

Participation in a Flexible Spending Account is completely optional. Whether or not you choose to participate,
you must complete an election form and return it to JANE HALVERSON by ____________________.

Listed below are some highlights of the Flexible Spending Accounts, which are important to remember.

        Health FSA claims are paid from the general assets of the plan sponsor. There is no separate fund
          or account that secures the promised benefit.

        The Plan Year is 1/1/2011 – 12/31/2011

        Annual Health Care Account maximum is $4420.00.

        Annual Health Care Account minimum is $26.00.

        Annual Limited Healthcare Reimbursement Account maximum is $4420.00.

        Annual Limited Healthcare Reimbursement Account minimum is $26.00.

        Annual Dependent Care Account maximum is $5000.00.

        Annual Dependent Care Account minimum is $0.00.

        After the plan year-ends, you have 90 Days to submit expenses incurred during that plan year.

        If your employment terminates during the plan year, you will have 90 Days to submit claims
          incurred up to your termination date.

        Be conservative, the IRS states that any unused funds will be forfeited.

        Your election will remain in effect for the entire plan year, unless you have a
          qualifying status change and the change is consistent with the qualifying event.

         Direct deposit carries over from year to year. ONLY new participants need to fill out a direct
          deposit form or existing participants making a change to the account which deposits are made.

         You may review your account details on our website at www.benefitadvantage.com

                                            Benefit Advantage, Inc.
                                            P.O. Box 5546
                                            De Pere, WI 54115-5546
                                            Phone: (920) 339-0351
                                            www.benefitadvantage.com
3431 Commodity Lane
                                                                                             GREATER GREEN BAY YMCA
Green Bay, WI 54304                                                EMPLOYEE ENROLLMENT FORM
Ph: (920) 339-0351
Fax:(920) 339-0038
                                                             PLEASE PRINT CLEARLY AND COMPLETE ALL INFORMATION

NAME:________________, ____________                                            SSN#:____-_____-______                               DOB: __________
            (LAST, FIRST, M)                                                                                                           (00/00/0000)
ADDRESS:_______________________________________E-MAIL:________________________

CITY:________________ STATE:___                                    ZIP:______                 WORK PHONE:_(____)____________

FIRST PAYROLL DATE:___-___-___COVERAGE EFF. DATE ___-____-____                                                         FREQUENCY:________
                                                                                                       (BI-WEEKLY, SEMI-MONTHLY, ETC.)

                                            Salary Redirection for Insurance Premiums
I understand that any eligible premiums I am obligated to pay for insurance coverage for my dependents and myself will be
deducted from my pay on a BEFORE-TAX basis unless I otherwise direct. This is in addition to the Flexible Spending
Account Elections below:

Please note that you may not elect again until the start of the new plan year unless you have a qualifying event. Please see
your Human Resources director for a list of qualifying events.
                                                        Healthcare Reimbursement Account

            Yes, I would like to participate in the Healthcare Reimbursement Account.
            Pay period Deduction $________ X #_____ of pay periods = $_________ Annual Election.
                                                                                   (PLEASE DO NOT ROUND)
            No, I choose not to participate.

                                          Day Care/ Dependent Care Spending Accounts

            Yes, I would like to participate in the Day Care/ Dependent Care Spending
            Per Pay period Deduction $_______ X #_____of pay periods = $__________ Annual Election.
                                                                             (PLEASE DO NOT ROUND)
            No, I choose not to participate.

                            Limited Healthcare Reimbursement Account—for HSA Participants Only

            Yes, I would like to participate in the Healthcare Reimbursement Account.
            Pay period Deduction $________ X #_____ of pay periods = $_________ Annual Election.
                                                                                   (PLEASE DO NOT ROUND)
            No, I choose not to participate.

* You will only be reimbursed from the Dependent Care Expense FSA to the extent that you have funded the account to date.

I understand that the choices I have indicated above must remain in effect for the entire plan year unless I have a change in family status. A change in family
status includes the birth or adoption of a child, marriage, divorce, death, spouse losing or gaining a job, or a change in employment status from part-time to full-
time or full-time to part-time.

I understand that the IRS requires any funds remaining in a flexible spending account at the end of the Plan Year must be forfeited by me to be returned to my
employer. I understand there is a 60 - 90 day grace period after the Plan Year end in which to submit expenses as long as the expenses were incurred within the
Plan Year. (Consult your employer to see which grace period applies.)

The effective date of the Plan Year and the end of the Plan Year should be verified with your Employer, (the Plan Administrator).

I hereby give my employer permission to reduce my salary by the above elected amounts.

Signature:                                                                         ______            Date: _______________________________
PO Box 5546
   De Pere, WI 54115-5546
   Phone (920) 339-0351
   Fax (920) 339-0038                                              GREATER GREEN BAY YMCA
                   FSA Authorization Agreement for Direct Deposit

Print Your Name: ___________________________________________________________________

Print Your SS#: ____________________________________________________________________

Effective Date: _____________________________________________________________________

The information listed below is necessary to completely process the direct deposit funds into a specific
bank account. (Please print all of the following information.)

    New                                       Change                                   Cancel

    Checking (Must attach voided check)                 Savings (Please verify information with bank)

 This information is for Benefit Advantage’s use only and will not be disclosed to an outside party.

 Transit ABA Routing #: __________________________________________________________

 Account Number #:        __________________________________________________________

 Name of Bank:            __________________________________________________________

 I authorize my Section 125 Health Care FSA, Dependent Care FSA, Transit & Parking FSA, and
 Section 105 HRA reimbursements to be sent to the financial institution listed above and to be
 deposited in the designated account. I understand I may direct deposit to only one bank account.

 In the event funds are deposited erroneously into my account, I authorize Benefit Advantage to debit
 my account not to exceed the original amount of the credit.

 I also understand that all direct deposits are made though the Automated Clearing House (ACH), and
 that funds availability is subject to the limitations of the ACH as well as my financial institution.
 Benefit Advantage will not be held liable for any bank fees, overdrafts, etc… associated with these
 reimbursements.

 Employee Signature:      _____________________________ Date: ___________________

Once Benefit Advantage receives this authorization, there is a 10-day waiting period before direct deposit
takes effect. Claims received within this period will be paid via check.

Return this form to address or fax number at the top of the page.
*To view account status online: www.benefitadvantage.com
# Pages
                 Mail:  PO Box 5546                                                                                                             ______
                        De Pere, WI 54115-5546
                 Fax:   (920) 339-0038
                 Phone: (800)686-6829                                                GREATER GREEN BAY YMCA
                                                                        FLEXIBLE SPENDING REQUEST CLAIM FORM
                         Last                                            First                      MI
   NAME:                                                                                                             SS#
                         Street                             City                          State     ZIP
   ADDRESS:                                                                                                          PHONE:          (     )
       Please check if this is a new address
 MUST FILL OUT                                      MEDICAL EXPENSE CLAIMS
                                              Date of Service
   Patient Name          Relationship          MM/DD/YY                 Name of Provider                 Claim Amount               Description of Service
      SAMPLE                    SAMPLE            SAMPLE                         SAMPLE                     SAMPLE                         SAMPLE
 John Doe                       Spouse           01/01/03                 Prevea Clinic                     $10.00                 Office Visit

                                                                                          Total:
YOU MUST ATTACH DOCUMENTATION THAT INCLUDES THE FOLLOWING INFORMATION FOR YOUR CLAIM TO BE PAID.
   Date(s) Service Performed,
   Type of Expense* (i.e. eye exam),
   Amount of expense incurred,
   Name of Patient, & Service Provider.
  *Codes are not appropriate form of a description of your expense.

                                              EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible dependents), were not reimbursed
by any other plan, and, to the best of my knowledge and belief, are eligible for reimbursement under my Reimbursement Plans. I (or we) will not use the expense
reimbursed through this account as deductions or credits when filing my (our) individual income tax return.

The Internal Revenue Service regulates this Flexible Spending Account. Our documentation guidelines are intended as a means to qualify your expenses for approval
and reimbursement. It is the responsibility of each participant to comply with these guidelines and to avoid submitting duplicate or ineligible claims. Failure to
comply with the above requirements will delay the payment of your claim. There is a $20 stop payment fee for all checks that need to be reissued due to no fault
of Benefit Advantage. Direct Deposit is available at no charge and is highly recommended.

Employee Signature: ____________________________________                                                        Date: ____________
        If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for balance details.

                             ***Original receipts will not be returned, please keep a copy for your own records. ***
                                                                                                11/17/2010
HOW TO FILE YOUR REQUEST

Definition of Medical Care:
Must be “for diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting
any structure or function of the body”. Special rules may apply.

STEP I
Complete ALL personal information on the reimbursement request form. All items you are requesting
reimbursement for should be itemized. Failure to complete your claim form could result in a delay or
denial of your claim.

STEP II

Attach proper documentation to the claim form.

All documentation included with your claim form must have the following listed: Date of Service,
Description of Service, Patient Name, Provider Name and Patient Responsibility. Credit Card receipts,
copies of Cancelled Checks, and Statements from your provider that list codes for a description are not
considered valid documentation. Cash register receipts for Over the Counter items must also list a
description of the item purchased.

If you have more claims than the spaces provided please attach additional claim forms.

STEP III
SIGN the request form.

Our goal is to process payments within 24 hours of receipt with proper documentation. We guarantee a
5 working day turnaround maximum.

This outline is intended for quick reference. If you have any additional questions, please call the
Flexible Spending Account Department at (920) 339-0351 or (800) 686-6829, available 8-4:30pm,
Monday through Thursday and 8-4 pm on Friday Central Standard Time.

               ***Original receipts will not be returned, please keep a copy for your own records. ***
                                                                                  11/17/2010
Benefit Advantage                                                                                 Phone: (920) 339-0351
P.O. Box 5546                                                                                     Fax:   (920) 339- 0038
De Pere, WI 54115-5546                                                                            Fax:   (920) 339-5736
                                 RECURRING ORTHO CARE
                              REIMBURSEMENT REQUEST FORM
    EMPLOYER NAME:                    GREATER GREEN BAY YMCA
    EMPLOYEE NAME:
    ADDRESS:

    SOCIAL SECURITY #:
    DAYTIME PHONE #:

    ORTHO CONTRACT MUST BE ATTACHED
    *This claim form is valid for one plan year
     I have attached a signed statement from the above stated Provider verifying the amount and frequency of
    charges. I agree that if the amount changes or if for any reason the expenses are not incurred as scheduled, I will
    notify Benefit Advantage immediately in writing.

    Name of Provider:
    For (Name of Patient)

The charge for the care is $                    per month, beginning on               /      /      & ending on           /        /     .

Start Date of treatment ___________                 Term of Treatment_____________________

I understand that reimbursements will be made only to the extent that my Flexible Spending Account annual
election allows. Any unused funds remaining in the account at the end of the plan year will be forfeited.

This claim form is only valid for the current plan year and will be posted to your Flexible Spending Account at the
end of the first full week of every month.
* If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for balance details.

                                      EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
 I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible
 dependents), were not reimbursed by any other plan, and, to the best of my knowledge and belief, are eligible for reimbursement
 under my Reimbursement Plans. I (or we) will not use the expense reimbursed through this account as deductions or credits when
 filing my (our) individual income tax return.

 Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
         files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.

Signature                                                               Date ______________________________
                   Plan Participant

                                                                                                         11/17/2010
# Pages
                  Mail:  PO Box 5546
                         De Pere, WI 54115-5546                                                                                ______
                  Fax:   (920) 339-0038
                  Phone: (800)686-6829
                                                                                    GREATER GREEN BAY YMCA
                                                                                DAYCARE REQUEST CLAIM FORM
                    Last                                           First
  NAME:             MI                                                                   SS#:
                       Street                            City
  ADDRESS:             State     ZIP                                                     PHONE :          (        )
   Please check if this is a new address

                                         DAYCARE EXPENSE CLAIMS
DATE OF SERVICE                  DEPENDENT DEPENDENT                             CLAIM               PROVIDER               *PROVIDER
FROM      TO                     NAME      BIRTH DATE                            AMOUNT              TAX ID#/SS#            NAME
                                                                                 $
                                                                                 $
                                                                                 $
                                                                                 $
                                                                                 $
                                                                                 $
                                                                Total:           $

*Please make sure you sign the bottom of this form.

PROVIDER VERIFICATION
* Signature of Provider mandatory if no Federal Tax ID is given above or documentation attached.
 I verify that the above charges are accurate as described.
 _____________________________________ _____________________                   ____________________
 Provider Signature                                 Federal Tax ID Number      Date
Please Note: The daycare provider must declare this as income on their tax return.

If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for
balance details.

Daycare expenses are reimbursed up to the cash balance in your account. Unpaid claims are reimbursed as more funds are
received from your employer and credited to your account.

  Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
   files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.

Employee Signature:                                                                       Date: ____________________
HOW TO FILE YOUR REQUEST

Definition of Dependent Care:
Must be for care of an eligible dependent by IRS regulations enabling you or your spouse to work, seek
employment, or attend school full-time.

Definition of Eligible Dependents:
The IRS states that an eligible dependent is less than 13 years old and living with you. An eligible dependent
may also include your mentally or physically impaired spouse/dependent/child who is living with you and
incapable of caring for him or her self.

*The provider of the care MUST declare the funds you pay them as income on their tax returns.

CHECKLIST                      Fill out only if you are manually submitting claims throughout the
                                year

                               Documentation must be attached

                               Sign the bottom of the claim form
Benefit Advantage                                                                                    Phone: (920) 339-0351
P.O. Box 5546                                                                                        Fax:   (920) 339- 0038
De Pere, WI 54115-5546                                                                               Fax:   (920) 339-5736
                                        RECURRING DAYCARE
                                    REIMBURSEMENT REQUEST FORM
             Please Print:
      EMPLOYER NAME:                     GREATER GREEN BAY YMCA
      EMPLOYEE NAME:
      ADDRESS:

      SOCIAL SECURITY #:
      DAYTIME PHONE #:

      I verify that I make regular ongoing payments to:
      Name of Day Care Provider:
      Provider Tax ID Number:
      For (Name of Dependent):
      Dependent Birth Date:
                                          This claim form is only valid for the current plan year.

The charge for the care is $                       per month, beginning on               /      /     & ending on            /      /      .

PROVIDER VERIFICATION
* Signature of Provider mandatory if no Federal Tax ID is given above or documentation attached.
I verify that the above charges are accurate as described.
_____________________________________ _____________________                                                ____________________
Provider Signature                                 Federal Tax ID Number                                   Date
Please Note: The daycare provider must declare this as income on their tax return.

     I agree that if the amount changes or if for any reason, such as illness or vacation, the expenses are not incurred as scheduled, I will
      notify Benefit Advantage immediately in writing.
     If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for balance details.
     A Recurring Claim allows Benefit Advantage to enter a claim on your behalf automatically at the beginning of each month. This is
      not a recurring payment. A claim will be posted to your Dependent Care Account at the end of the first full week of every month.
      Reimbursements to you will occur as funds are received by Benefit Advantage from your employer. Deposit dates may vary month to
      month. Benefit Advantage will not be held responsible for any late charges or overdraft fees related to the payment of your daycare
      provider.

    Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
            files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.

Employee Signature:                                                                          Date: ____________________
                                         Plan Participant
HOW TO FILE YOUR REQUEST

Definition of Dependent Care:
Must be “for care of an eligible dependent by IRS regulations enabling you or your spouse to work or to seek
employment”

Definition of Eligible Dependents:
The IRS states an eligible dependent is less than 13 years old and living with you. An eligible dependent may
also include your mentally or physically impaired spouse/dependent/child who is living with you and
incapable of caring for him or her self.

*The provider of the care MUST declare the funds you pay them as income

CHECKLIST                            Make sure you complete the entire form:

                                      Enter amount paid to daycare provider per month

                                      Enter Begin Date of the recurring costs

                                      Enter End Date of plan year or date no longer have daycare costs

                                      Enter Dependents Name

                                      Enter Dependents Date of Birth

                                      Have Provider Sign Claim Form and enter Tax Id # or SS#

                                      Sign the bottom of the claim form
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