American Association of State Troopers (AAST)
right308610AAST HEALTH/ FITNESS CENTER REIMBURSEMENT FORM020000AAST HEALTH/ FITNESS CENTER REIMBURSEMENT FORMAAST members are eligible for reimbursement once per calendar year. You must be an AAST member and a participating member of an approved health and fitness program for at least four consecutive months in the calendar year.Reimbursement should be submitted for the current year between:May 1st of the current year, and March 31st of the following calendar yearAAST will reimburse only for the amount reflected on those receipts/statements up to $100 per AAST member.Section 1 – Member Information (as it appears on AAST ID card)_______________________________________________________ __________Last NameFirst NameMid Initial______________________________________________________ _______________Mailing Address Telephone numberSection 2 – Health/Fitness Center InformationName/Address/Type of facility or activity Year* Amount **You can only file one Fitness Benefit claim form for any calendar year. Thus, to be reimbursed for two or more qualifying expenses, each expense must be included on the same claim form.*Calendar year is the 12-month period, beginning January 1 and ending December 31, for which reimbursement is being requested.** You can request up to $100 per memberSection 3 – Information for ReimbursementPleases submit each item and check off the boxes below:left444500Completed formleft444500A copy of any/all applicable health center contracts or agreements. These must show the beginning and ending dates of membership activity and the names of enrolled members.63509969500Dated copies of receipts or bank/credit statement showing the charge for membership or classes. These should reflect the dollar amount you are requesting. AAST will reimburse only for the amount reflected on those receipts/statements up to $100 per member.Certification and Authorization (This form must be signed and dated below by the AAST member.)Reimbursement subject to approval by AAST. All payments will be made with member’s authorization. Members’ signature required. Please allow 30 days from receipt for reimbursements. To the best of my knowledge and belief, my statement in the Health/Fitness Center Reimbursement Form are complete and true.Members: I am claiming reimbursement only for eligible expenses incurred during the applicable calendar year. I certify that these expenses have not previously been reimbursed in this or any calendar year.________________________________________________Member SignatureDate5334003238500I would like to donate my Health/Fitness reimbursement to the AAST Scholarship Foundation; by checking the box I am authorizing my reimbursement for the current claim year be processed and paid to the AAST Foundation.Mail this form and back up documents to: AAST – Wellness Benefit 1949 Raymond Diehl Road Tallahassee, FL 32308! Remember to keep a copy of all documentation before sending in your Health/Fitness reimbursement form.If you have any questions regarding this benefit please call the AAST National office 800-765-5456 3/22/18 ................
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