HR Gym Reimbursement - Create A New Application - Franklin County Benefits and Wellness

Q3 2023 Gym Membership Reimbursement Form

In order to process your application, we ask you to provide the following information. Please note that all fields marked with an asterisk (*) are required.

Employee Information

First Name *

Last Name *

Email Address *

Agency *

What County do you work in? *

Hired Less Than Six Months Ago

Date of Birth *

Month Hired *

;

Employee ID/MUNIS ID *

Last 4 Employee SSN *

Spouse First Name

Spouse Last Name

If submitting a spouse, remember 1 form per household.

Gym Information (including Orange Theory, Yoga, Jazzercise, Curves, etc.)

Gym Name *

Gym Telephone # *

Gym Address 1 *

Gym Address 2

Gym City *

Gym State

Gym Zip Code *

Additional Gym

Amount Requested

Amount requested for reimbursement *

The maximum reimbursement amount is $75 per quarter.

Proof of Attendance and Proof of Payment

Attach documentation from your gym providing proof of attendance and your proof of payment.
Your proof of attendance must include your name, your gym name, and the dates visited each month.
You must attend a gym or gym(s) a minimum of 8x/month.
If you are combining visits from two gyms you must fill out the gym information section and provide proof of visits/payment for both facilities.

Your proof of payment must include your name, your gym name, and the amount paid each month.
Proof of payment must be provided for all months and/or class dates requesting reimbursement.

Please upload documents only in 'csv, 'doc', 'docx','gif, 'jpg', 'jpeg', 'pdf', & 'png' format.

My Documents

(Please select one file at a time)

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Required Signature

Please check the box to provide your digital signature.

Signed Date

10/03/2023

By checking this box I affirm that all of the information provided is full, complete and true to the best of my knowledge. False statements are considered fraud against the plan. I acknowledge that checking this box serves as my signature.