ADOPTION ASSISTANCE REIMBURSEMENT FORM

Important: Please print clearly and be sure all sections are complete to avoid delays in processing. Mail the Adoption Assistance Reimbursement Form directly to the Life Programs Administrator along with all the original receipts. Each receipt must show the dates and nature of the services provided. Reimbursement forms will not be processed without original receipts. Keep photocopies for your personal records. Questions? Please contact the Employee Service Contact Centre at 1-866-214-0977 or send an email to ESHelp/CanWest/IBM or eshelp@ca.ibm.com

A Employee Information
____________________________________________ Employee Name _____________________________________________ Name of the child _____/______/______/______ Employees Internal Address ________ (____)__________ Serial # Business Phone (____)__________ Home Phone

_____________________________________ Date child was placed in home

______________________ VM Node/ID or Notes id

B Adoption Expenses Section

Charge Description ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ TOTAL CHARGES $_____________ $_____________ $_____________ $_____________ $_____________

Is assistance towards these charges provided from any federal, provincial or local government agency, private organization or other source? (Y/N) ____ If Yes, please provide details :_ _________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

Employees Authorization and Signature

I certify that: The information in this form is true and complete and does not contain a claim for any expenses previously paid for by this or any other organization. I am eligible for coverage under the IBM Adoption Assistance Plan. I read and agree with the terms and conditions of the IBM Adoption Assistance Plan listed below. ___________________ ___________ Employee Signature Date

D Privacy Information
The information collected in the Refund Form is kept confidential and is not disclosed to any other source. For more information please review IBM's Privacy Policy posted in the W3

Terms and Conditions

IBM reserves the right to modify (include change, discontinue, suspend or improve) any of its plans, programs, policies or statements at its discretion and IBM's decision on all matters relating to the operation, administration and interpretation of its plans, programs, policies or statements shall be final. The IBM plan administrator retains exclusive authority and discretion to interpret the terms of the plan. This statement applies to all IBM employees (regular full-time, special/regular part-time, assignees, on leave), individuals receiving Short or Long Term benefits income, retirees and survivors. Nothing contained in this document shall be construed as creating an express or implied obligation on the part of IBM to maintain such benefit plans, programs, practices or policies.

Mailing Instructions Keep a copy of your form and receipts for your records
Life Programs Administrator (B2/3600/MKM) IBM Canada Ltd. 3600 Steeles Avenue East Markham, Ontario L3R 9Z7

Mail your completed and original receipts to :

FOR IBM USE ONLY

Amount previously claimed for this child Total receipts this claim Less amount rec'd from other sources Reimbursement level @ 80% Total Reimbursement (Up to $1500.00 Maximum per child) $________ $________ $________ $________ $________