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					           2010 CWS HealthSmart Wellness Reimbursement Request

            All purchases must be PRE-APPROVED by your supervisor
Associate Name:                                                                Hire Date:
Please Check One:                      Full-Time           Part-Time
Dept/Entity #:

Please check one:                   6110.0022 (On-site)                      6129.0020 (Corporate)

Please select the type of reimbursement you are requesting:

       Gym Membership/Exercise Class                                Total Receipt(s):                           $
       Tobacco Cessation ($500 bonus/please
           contact Sylvia at 512.682.6931)
       Weight Management                                            Amount to be Reimbursed:                    $
       Equipment Reimbursement
Description of Equipment Purchase:

Authenticity Statement:
The attached original receipt verifies my purchase of the item indicated above. I understand the purchase must be pre-
approved by my manager and that reimbursements are limited to up to $100 for full-time employees & $50 for part-time
employees and that this payment may be considered a taxable fringe benefit.

Associate Signature:
Supervisor Approval:

      Send completed form with receipt to the Human Resources-Benefits department.

Human Resource Use:
HR Approval:                                                                   Date:
Submitted to Acct:

Guidelines for Reimbursements:
 Only requests with original receipts will be eligible for reimbursement. Copies, including faxed copies will not be
 New associates are eligible for wellness reimbursements on the 1st of the month after 60 days of employment. Reimbursement
    amounts are pro-rated based on eligibility date.
 Receipts reflecting the use of gift cards will be reimbursed for the total amount less the gift card amount.
 Gym Memberships: Statement/Invoice reflecting your name and the amount that you have paid must be included. You may provide
    copies of bank or credit card statements as well that reflect your name and the amounts paid. Please delete/mark out
    personal/confidential information.
 Equipment Reimbursements: This option is for exercise and weight training equipment. Deadline: 2010 Deadline for
    reimbursements is Friday, December 17. Requests received after 12/17/10 will be for the 2011 wellness plan. Purchases for the next
    year must be made after 12/17/10.
 Clothes purchases will not be reimbursed.
 Please expect 2-3 weeks for processing.

Revised 1/14/10