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<br /> <br />TML Intergovernmental Employee Benefits Pool <br />PO Box 140167 <br />Austin, Texas 78714-0167 <br />Fax: (512) 719-6505 <br /> <br />IITML <br /> <br />~ Intergovernmental <br />Employee Benefits <br />Pool <br /> <br />Employer Name Employer Group # <br />Employee Name Social Security # <br />Street Address City State Zip Code o Check here if new <br /> <br />UNREIMBURSED HEAI,TH CARE REIMBURSEMENT FORM. <br /> <br />Incurred Total Amount Amount paid by Amount to be Expense for: <br />Date of Bill any Plan Reimbursed (Name) <br /> $ $ $ <br /> $ $ $ <br /> $ $ $ <br /> $ $ $ <br /> $ $ $ <br /> $ $ $ <br /> <br />Description of <br />Eligible Expense <br /> <br />TOTAL <br /> <br />AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are <br />dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses <br />incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible' <br />Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant <br />change in cost or coverage of my health plan or my spouse's health plan or separation from service as prescribed by IRS rules. If a change in <br />family status occurs, you have 31 days from the occurrence to change or revoke your election. Furthermore. I hereby authorize my employer to <br />transfer my required health benefits contribution on a monthly basis to the TML Intergovernmental Employee Benefits Pool. <br /> <br />Employee Signature <br /> <br />Date <br /> <br />CONFIDENTIALITY NOTICE: The infonnation contained in this transmission, including any attachments, is for the sole use of the intended <br />recipient(s) and may contain confidential and privileged infonnation. Any unauthorized review, use, disclosure, or distribution is prohibited by <br />Federal law. If you are not the intended recipient of this message, you are notified that you may not disclose, print, copy, or disseminate this <br />infonnation. If you have received this transmission in error, please reply to the sender and delete or destroy the message. Unauthorized <br />interception of this transmission may be a violation of criminal law <br />