FITNESS REIMBURSEMENT BENEFIT

All regular full-time and part-time employees of Freewebs are eligible to take advantage of this
benefit. It is designed to provide greater flexibility in choosing a fitness activity/center to meet
individual needs.

Freewebs will reimburse 50% for eligible physical fitness activities up to a maximum of
$25/month or $75/quarter.
If the activity includes lessons, a minimum of 3 lessons is required for the activity to
qualify for this benefit.

To be eligible for reimbursement the physical fitness activity must focus on the means to
maintaining a healthy and fit lifestyle. Physical fitness activities should include the following
components: endurance, aerobic activity and strength training. The following is a sample of
activities that meet the new definition and may be submitted for reimbursement:

Fitness club dues

Intramural team dues (e.g., soccer, basketball, lacrosse)
Fitness Trainer
Yoga
Pilates
Aquatic centers
Karate or Kick Boxing

Activities that are not covered:

Any leisure activities, social clubs, country clubs, public park access fees, golf greens fees,
donation-driven activities (i.e. Marine Marathon training program), bungee jumping, parachuting
or parasailing. Equipment used for the activity such as: shoes, uniforms and home training
equipment are not covered.
Note: The contract you sign with a fitness program is solely your obligation; Freewebs does not
act as a liaison between the member and the fitness program.
Due dates:
Reimbursements will be paid as a reimbursement check from Accounts Payable and are issued in
the reimbursement month for each quarter provided that a completed Fitness Reimbursement
Request and applicable receipt(s) are submitted no later than the due date listed in the chart
below. These reimbursements are a taxable fringe benefit and will be added to your wages each
year. The TFB tax will be assessed and noted on your check advice at the end of the calendar
year. Remember to keep copies of receipts for your records. Reimbursement requests must be
received no later than the due date indicated. The following timeline is provided to determine
when to submit the Fitness Reimbursement Form to HR:

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Quarter in which dues were

paid

Due Date

Reimbursement
Payroll

January, February, March 2015

April 16,
2015

April 24, 2015

April, May, June 2015

July, August, September 2015
October, November, December
2015

July 23,
2015
Oct 15,
2015
Jan 21,
2016

July 31, 2015

October 23, 2015
January 29, 2016

If you pay dues to your club/center on an annual basis, just submit your receipt of the annual
dues payment only one time no later than the due date for the quarter in which the annual dues
were paid. You will then be reimbursed quarterly. Be sure to indicate on the Physical Fitness
Reimbursement Form that you are submitting a receipt for the full year.

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Fitness Reimbursement Request

Complete Sections I, II, and III, and attach any receipt for which you have paid club dues
before submit this form and the receipt to AP. Reimbursement will only be made if request is
accompanied by the appropriate documentation. Requests must be received no later than
April 16th .
I. Employee Information
Name

Alvin Singletary Jr

Date Submitted 7/7/2016

II. Fitness Club Information

Name of Physical Fitness Activity you are/will be attending

Reimbursement Period (Check One):

Q1=3/31

Planet Fitness
Contract Term (Example January 1, 2014 December 31, 2014): If applicable
January 2016-December 2016

Total Dues Paid by Employee:

Year:

Q2=6/30

Q3=9/30

X Q4=12/31

2016

Total Reimbursement Amount: 29.99

III. Signature
I understand the foregoing to be true and complete to the best of my knowledge. I understand Freewebs will only reimburse 50% up to a
$25 monthly maximum. For fitness clubs, this reimbursement is for the employees monthly membership fees only. Initiation fees are not
eligible for reimbursement. This reimbursement will be based on Freewebs definition of a physical fitness activity only. Completion of this
form does not guarantee payment and/or my eligibility. I understand the reimbursement is considered a taxable fringe benefit.
Employees
Signature Alvin
Singletary Jr

Date

4/4/2016

Planet Fitness
Annual Club Dues
Monthly Dues ($500/12 months)

19.99

50% of Monthly Dues

9.99

29.99

Quarterly Reimbursement Amount ($20.83 x 3

months)

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$ 239.88

This is the total dollar amount that is eligible for reimbursement for the
quarter. Place this amount on the line labeled Total Reimbursement
Amount, in section II.