To the best of my knowledge and belief, my statements in this Reimbursement Request Form are complete and true. I certify that I or my family member
has received the services described above on the dates indicated, that the expenses qualify as valid medical services under the Plan. If the expense is for my spouse or
dependent, I certify that the person listed is my spouse or meets the definition of dependent in the plan. I certify that I have not been reimbursed previously for these
expenses under the Medical Reimbursement Component Plan. I certify that these expenses have not been reimbursed, and are not reimbursable under the Major Medical Plan or
any other health plan, such as my spouse's plan. If the reimbursement is requested for prescribed drugs, I certify that such drugs are not prescribed for cosmetic
purposes (hair growth, weight loss, etc.). I understand that the expenses I am reimbursed may not be used to claim any federal income tax deduction or credit. I authorize
a deduction in my Medical Reimbursement Account in the amount of the reimbursement.