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© Hitesman & Wold, P.A. 2019 Cafeteria Plan Summary Description (3-11) 49 (4) You must certify proper use of the card. As specified in the Cardholder Agreement, you certify during the applicable Plan Year that the amounts in your account will only be used for Eligible Expenses (i.e., medical care expenses incurred by you, your spouse, and your tax dependents), that you have not been reimbursed for the expense and that you will not seek reimbursement for the expense from any other source, and that you will obtain and retain a third party statement from the health care provider (e.g., receipt, invoice, etc.) each time you swipe the card. Failure to abide by this certification will result in termination of card use privileges. (5) Reimbursement under the card is limited to certain places where you purchase health care related items. Use of the card is limited to merchants who: (i) have health care related merchant category codes other than the drug store or pharmacies merchant category code; (ii) have the drug store or pharmacies merchant category code and with respect to whom 90% of the store’s gross receipts during the prior taxable year consisted of items that qualify as expenses for medical care under Section 213(d) of the Code (a “90% pharmacy”); or (iii) participate in an inventory information approval system developed by the card provider that verifies, at the time of purchase, that the goods being purchased constitute medical care. (6) You swipe the card at the health care provider like you do any other credit or debit card. When you incur an Eligible Expense at a doctor’s office or pharmacy, such as a co-payment or prescription drug expense, you swipe the card at the provider’s office much like you would a typical credit or debit card . The provider is paid for the expense up to the maximum reimbursement amount available under your Limited Scope account (or as otherwise limited by the program) at the time you swipe the card. Every time you swipe the card, you certify to the Plan that the expense for which payment is being made is an Eligible Expense and that you have not been reimbursed by any other source nor will you seek reimbursement from another source. (7) You must obtain and retain a receipt/third party statement each time you swipe the card. You must obtain a third party statement from the health care provider (e.g. receipt, invoice, etc.) each time you swipe the card that includes the following information: (i) The nature of the expense (e.g. what type of service or treatment was provided). If the expense is for an over the counter drug, the written statement must indicate the name of the drug; (ii) The date the expense was incurred; and (iii) The amount of the expense. Although it is not required to be submitted for all purchases, you must retain this receipt for one year following the close of the Plan Year in which the expense was incurred. Even though payment may be made under the card arrangement, a written third party statement may be required to be submitted (except as otherwise provided in the Cardholder Agreement). You will receive a letter from the Claims Administrator if a third party statement is needed. If requested, you must provide the third party statement to the Claims Administrator within 30 days (or such longer period provided in the letter from the Claims Administrator) of the request.