Retiree Subsidy Annual Certification by Participant / Beneficiary Form

Annual Retiree Subsidy Certification

This forms needs to be filled out and submitted in January of each year to report the amount of your retiree subsidy you spent the previous year. Any amount received in a year that was not spent that year will be noted on a 990 tax form and sent to you to submit with your taxes. Ideally you would have spent 100% of the subsidy on IRS qualified expenses like health care premiums, prescriptions and out of pocket medical expenses. For a list of IRS qualified expenses go to https://www.irs.gov/publications/p502.

First Name *

Last Name *

Email Address *

Other Medical Expenses *

Social Security Number *

Address *

City *

State *

Zip *

Is this a new address?

Home Phone *

Mobile Phone *

Name of Insurance Company

Amount of Subsidy Spent in Premiums this Year

Other Qualified Medical Expense (Prescriptions, Equipment, Services, Hospitalization, Vision Care)

Amount

Other Qualified Medical Expense (Prescriptions, Equipment, Services, Hospitalization, Vision Care)

Amount

Additional Comments

The undersigned further certifies that all funds received from the United Arizona Firefighters Health Care Trust Fund have been or will be expended solely for reimbursement of health insurance premiums or medical expenses and that the amount spent by the undersigned equals or exceeds the amount he or she will receive from the fund.

Signature

Clear Signature

Date / Time

Date

Time

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