BOARD OF

ADMINISTRATION LABOR

John Ballantyne

Co – Chairman

Thomas Breslin

Dave Haines

Michael Hand

Michael Morrow

Robert Naughton

MANAGEMENT

James R. Davis

Co – Chairman

Joseph Clearkin

Benjamin Connors

Jack Healy

Frank Lutter

Philip Radomski

CO-COUNSEL

Jennings Sigmond P.C. & Thomas

J. McGoldrick Esq

1811 Spring Garden Street

Philadelphia, PA 19130

Phone 215-568-0430

www.carpenters.fund

March 17, 2017

Re: Vacation (Dependent Care) & Health Reimbursement Account (HRA)

Dear Participant,

The first payment(s) under the newly revised Vacation (Dependent Care) and HRA Plan (if

applicable) will begin in May 2017. Here is what you need to know about these Benefits.

Vacation Benefit / Dependent Care Flexible Spending Account (FSA):

The Vacation Benefit will be issued automatically to eligible participants on each of the

quarterly vacation payment months (February, May, August, and November).

If you elect(ed) Dependent Care FSA benefits on your annual Cafeteria Claim Form, you

will need to submit a Dependent Care Reimbursement Form to the Fund Office. Include

with the Reimbursement Form a statement detailing the services provided, the name of

the provider, tax identification number/social security number, the date of service, and

cost of service with proof of payment. Only submit expenses for eligible dependents.

Providers must sign the Affidavit section of the Reimbursement Form if they are Private

Residence Providers and you do not have supporting documents.

Health Reimbursement Account (HRA) Withdrawal Requests:

An HRA Claim Form must accompany all requests. You will be able to complete the Claim

Form and upload your receipts online at www.carpenters.fund, the carpenters.fund

mobile app or download a copy for mailing purposes. Approved claims will be deposited

on the following quarterly HRA payment months (February, May, August, and November).

Electronic Payment:

The Fund Office will no longer issue paper checks. All payments are now electronic and

will be deposited into the financial institution of your choosing. If the Fund Office already

has your bank account information on file, all payments will be directly deposited into

that account. If no banking information is provided, an account will be created for you at

the Union Building Trades Federal Credit Union. (See insert for more Credit Union

account details). Go to www.carpenters.fund or use the mobile app to update or change

your banking information.

Enclosed:

Health Reimbursement Account (HRA) Claim Form

Dependent Care Reimbursement Form

HRA Claims & Dependent Care Reimbursement Frequently Asked Questions (FAQs)

Credit Union Account information

Timely filing for any claim is one year from the date services were rendered.

HRA Qualified Health Care Expenses ( Please complete and sign below.)

HRA CLAIM FORM

Upload your receipts fast and easy at www.carpenters.fund

Participant Name: _________________________________________________ UBC # or Last Four of SSN: _________________________

Item No.

Date of Service Name of Provider Expense Description (Medical, Dental, Prescriptions)

Claim Amount

1

2

3

4

5

For each expense claimed (Medical, Dental, Orthodontic, Prescription, and Optical), submit a receipt or state-

ment detailing the services provided, the name of patient, the date of service, diagnosis (if available), cost of service with

proof of payment and an Explanation of Benefits (EOB) from any other insurance carrier or plan (if applicable). Expenses

may only be submitted for you and your Eligible Family Members. Include a doctor’s note when required.

For Medical Insurance Premium Reimbursement: Submit pay stubs clearly showing deductions for medical premiums

are after taxes. If it is not clearly stated on the paystub, a letter is required from the employer verifying they are POST-

TAX deductions for health insurance benefits. The letter must include the medical premium cost to the em-

ployee, name of person the payment for health insurance is issued to, check date and company name.

Clearly legible photocopies of original receipts may be uploaded online at www.carpenters.fund

For information regarding eligible medical expenses, please refer to IRS Publication 502 (Medical Dental Expenses). WWW.IRS.GOV

$

I acknowledge that the Plan shall pay or reimburse approved expenses from my account up to the account balance. I also certify that

any eligible medical expenses submitted for reimbursement are for myself, my spouse, or Eligible Family Members and such expenses

have not and will not be reimbursed under any other Health Savings Account, insurance plan or claimed as a deduction on a tax return

or tax deductible Plan.

Total Amount Requested

Participant Signature: _________________________________________________________________Date: ______________________________

Additional claim boxes located on the back of this form.

Item No.

Date of Service Name of Provider Expense Description Claim Amount

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Qualified Health Care Expenses ( Please complete all applicable spaces)

$ TOTAL

Participant Name: ___________________________________________________ UBC # or Last Four of SSN:_________________________

Upload your receipts fast and easy at www.carpenters.fund

Health Reimbursement Account (HRA)

How do I become eligible for a Health Reimburse-

ment Account (HRA)?

You are eligible for an HRA Account if: (1) you satisfy

the general Plan rules for eligibility for health benefits

for active employee contributions and (2) the wage

and benefit package for your work has a “Cafeteria

Benefit” contribution of $1.00 per hour or more or the

Board allocates a portion of the Health & Welfare con-

tribution for your work to an HRA account.

What expenses can the Health Reimbursement

Account (HRA) pay?

Current tax laws require that the Plan limit HRA bene-

fits to payment of health care expenses. The HRA ac-

count can be used to reimburse you for eligible health

care expenses:

Incurred and paid for you, your eligible Spouse

and your eligible Children for eligible goods or ser-

vices after December 31, 2016.

for diagnosis, cure, mitigation, treatment or pre-

vention of disease or treatments affecting any

part or function of the body;

which are not otherwise compensable by (or the

responsibility of) an insurance carrier, a plan or

other third party, and

Could be claimed as a medical expense deduction

on a federal income tax return (without regard to

limitations on deductibility based on a percentage

of your income).

How do I claim benefits from my HRA?

You can claim reimbursement from the HRA after a

credit is made to an HRA for you. Once a credit is

made to your account, you can submit claims for eligi-

ble health care expenses to the Fund office using the

HRA Claim Form.

You can submit claims as you pay eligible expenses.

The Plan will collect claims and reimburse you on a

quarterly basis up to the balance in your HRA. All

claims for a calendar year must be submitted to the

Plan within one year after the date of service.

For expenses over $500, you can submit the bill to the

Fund Office for payment directly to a provider as long

as your account has sufficient fund to cover the ex-

pense.

A claim for HRA expense reimbursement must be

made on a Plan Form or submitted online at

www.carpenters.fund and include the documentation

required to support a deduction of the expense as a

medical expense deduction under IRC Section 213

(disregarding the limitation based on adjusted gross

income in that section) and such other information as

deemed necessary by the Plan. The current regula-

tions under IRC Section 213 require that you substan-

tiate medical expenses with written documentation

showing:

the name and address of each person to whom

payment was made.

the date and amount of each payment, and

a statement or itemized invoice from the individu-

al or entity to whom payment was made showing

the medical nature of the expense.

The Plan will need bills and evidence of payment to

support your claim and show that it was not compen-

sated by insurance or other means. It can require ad-

ditional information beyond the claim form to assure

that your claim is eligible for reimbursement. A claim

can be denied for failure to submit supporting docu-

mentation on a timely basis.

For a list of HRA Eligible Expenses for Reimbursement,

please visit the Cafeteria Plan & HRA Benefit page at

www.carpenters.fund

You must submit all claims for reimbursement of Dependent Care Expenses incurred during a calendar year by February

1st of the following calendar year or the amount may be forfeited.

Qualified Dependent Care Expenses ( Please complete and sign below.)

DEPENDENT CARE

Upload your receipts fast and easy at www.carpenters.fund

Participant Name: ________________________________________________ UBC # or Last Four of SSN: ___________________________

Item No.

Date of Service

End Date of Service

Name of Provider Provider Tax ID or SSN Expense Covers

(Dependent Name)

1

2

3

For each Dependent Care Expense claimed for reimbursement, submit a statement detailing the services pro-

vided, the name of the provider, tax identification number or social security number, the date of service, and the cost of

service with proof of payment.

Expenses may only be submitted for qualifying dependents. Providers must sign the Affidavit below if they are Private

Residence Providers and you do not have these supporting documents.

Clearly legible photocopies of original statements may be uploaded online at www.carpenters.fund.

You are encouraged to consult your personal tax advisor or IRS Publication 503 (Child and Dependent Care Expenses) at WWW.IRS.GOV for fur-

ther guidance as to what is or is not a Dependent Care Expense if you have any doubts.

I acknowledge that the Plan shall pay or reimburse approved expenses from my account up to the account balance. I also certify that

any eligible Dependent Care Expenses submitted for reimbursement are for Qualified Dependents and such expenses have not and will

not be reimbursed under any other Dependent Care Flexible Spending Account, insurance plan or claimed as a deduction on a tax re-

turn or tax deductible Plan.

Total Amount Requested

Participant Signature: ________________________________________________________________Date:______________________________

REIMBURSEMENT FORM

AFFIDAVIT:

Your daycare provider only needs to sign this if they are a Private Residence Provider and you do not have the supporting

documents as described above.

I hereby certify that I provided adult or child daycare services to the above individual(s) in accordance to the amounts and

dates that are requested.

Provider’s Signature: _________________________________________________________________Date:______________________________

$

How do I become eligible for the Dependent Care

FSA?

You are eligible for the Dependent Care FSA if: (1) you

are eligible for a Vacation Benefit under the Plan, and

(2) make a timely election to allocate a portion of the

Vacation Benefit payments to the Dependent Care

FSA.

How do I elect the Dependent Care FSA?

You can elect Dependent Care FSA benefits during the

annual election period in the month of December.

You must complete a Reimbursement Form from the

Fund Office to allocate part of your Vacation Benefit to

the Dependent Care FSA and return it to the Fund

Office by the annual deadline.

How does the Dependent Care FSA work?

You can allocate Vacation Benefit money to the De-

pendent Care FSA up to an annual maximum under

Section 129 of the Internal Revenue Code (IRC). The

maximum current annual limit generally is $5,000 per

year. The limit is $2,500 if you are married and reside

together, but file a separate federal income tax return

and also cannot exceed the lesser of the earned in-

come (as defined in IRC Section 32) of you or your

spouse (with a special limit for student and disabled

spouses). The more practical limit is the sum of your

Vacation Benefit payments which are the most you

can allocate to the Dependent Care FSA.

If you elect to allocate Vacation Benefit money to the

Dependent Care FSA, a non-interest bearing depend-

ent care account will be set up to keep a record of

claims and payments for the Dependent Care Reim-

bursements to you. The Dependent Care FSA is not an

actual account; it is merely a bookkeeping account in

the Fund office.

When you complete a Vacation / Dependent Care

form with an allocation to the Dependent Care FSA,

your quarterly Vacation Benefit payments will be allo-

cated to the Dependent Care FSA until the FSA alloca-

tion is funded.

How do I claim reimbursement under the Depend-

ent Care FSA?

When you incur an eligible Dependent Care Expense,

you submit a claim to the Fund Office on the Depend-

ent Reimbursement Claim Form, which may require

details on the provider and proof of payment or a

debt for a Dependent Care Expense.

If your Dependent Care FSA balance is sufficient,

you will be reimbursed for your Dependent Care

Expenses on the next scheduled processing date.

If your claim was for an amount that was more

than your current Dependent Care Account bal-

ance, the excess part of the claim will be carried

over into following months, to be paid out as your

balance becomes adequate.

However, you cannot be reimbursed for any ex-

penses above your annual payments to your De-

pendent Care FSA or for any expense incurred

after the close of the Plan Year.

You will be notified in writing if any claim for benefits

is denied.

You must submit all claims for reimbursement of De-

pendent Care Expenses incurred during a calendar

year by February 1st of the following calendar year or

the amount may be forfeited.

For more information about the Dependent Care FSA

please visit the Cafeteria Plan & HRA Benefit page at

www.carpenters.fund

Dependent Care Flexible Spending Account (FSA)

www.ubtfcu.org

800-848-2438

Vacation, Dependent Care & HRA Benefits

You have the option of having your Vacation, Dependent Care & HRA Benefit deposits forwarded to the credit un-ion for your immediate use. If you would like this option, please contact the Carpenters Benefit Funds of Philadel-phia office at (215) 568-0430. Deposits are sent to the credit union on a quarterly basis and are available for immediate withdrawal. You can access your funds by calling the credit union and they will mail a check to your address. You will need provide two (2) forms of identification, one from a Primary source and one from a Secondary source (see examples below).

Primary: Current photo driver’s license, valid photo state/government issued ID with, or passport.

Secondary: Social Security card, utility bill issued in the past 90 days that shows current address, or Union Card.

Credit Union Membership

Please Note: In order to take advantage the services and benefits of the credit union, (debit card, online access, bill pay service) you need to fill out the credit union membership application. (Note: this application is available on the credit union website listed above). Membership in the credit union offers a full array of banking services at no cost to you. More detailed information about their products and services is available on their website. You will have the option to have your Local Union Dues automatically deducted from your account. Members of your immediate family (by blood or marriage) are also eligible for credit union membership.

If you already have banking information on file with the Benefit Fund Office and would like to switch to

the credit union account, please visit the forms page at www.carpenters.fund to remove your Direct Deposit account information.