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1 The BEST flex f FLE Plan Reimbursement Form Make a photocopy of this form Please print Fill out form completely Please Complete When Faxing: Return Fax Number Date No. of Pages SM Section 125 Administration

I understand that it is the responsibility of my Company Plan representative to verify this claim. Signed, Aged 30 years of age or older In the State of NY, New York Name: (Your full name or first name) Address: (Your Address) City or State: State/Province/Region: Zip/Postal: Fax Number: (Your Fax Number) If Filing by Mail: If you are filing this claim by mail, put the completed PDF claim form, the appropriate supporting documentation, and either “claim/tax return” or “bill” on one side of the envelope and then mail the claim form, the supporting documentation, and/or “bill” to: Lemon Creek Tax Plan 3120 S. W. State, Suite #300 Palm Desert, CA 92 Mail to: Lemon Creek Tax Plan 3120 S. W. State, Suite #300 Palm Desert, CA 92 Phone: Frequently Asked Questions (FAQ) Q. What is my tax liability? A. Your liability for tax includes income you claim for tax deductions. The tax liability includes income you receive, such as a bonus from your employer, and is also what you would have received if the employer had reported the amounts properly. Your tax liability excludes amounts that you receive as a participant in a 401(k), governmental plan, or IRA. Lemon Creek Tax Plan's Eligibility Requirements Q. Am I considered a “taxpayer” by my employer? A. There are two requirements that must be met prior to the plan administrator reviewing all available tax return information and requesting tax returns from participants for the benefit of everyone: 1) The employee must be an individual taxpayer 2) The employee must be filing a return for the year of the plan. The plan administrator cannot request an employer's tax return from individuals without IRS permission. Q. Is this plan for me? A. No. The plan is for participants over 18 years of age. In some situations, if you meet the other criterion, you may still be disqualified. For example, if you are a participant in a plan that is operated by a separate business entity, you are disqualified if you have been a shareholder of that business entity in a past year.

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