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TOBACCO AFFIDAVIT FOR CITY OF BLACKFOOT EMPLOYEES & COVERED SPOUSES 2025 Please return form to Greg Austin at City Hall no later than February 1st, 2025. Fax: [PHONE REDACTED] or email to [EMAIL REDACTED]. Please complete (Print) Last Name First Name Middle Initial Home Address (Street Address/City/State/Zip) Email Address Work Phone No. As part of the City of Blackfoot’s initiative to encourage employee wellness, those employees who are tobacco users and annually complete the city-sponsored tobacco cessation program will receive an additional employer contribution toward their health insurance premium beginning October 1, 2020. A tobacco user is defined as a person who has smoked or used any tobacco products, such as cigarettes (including but not limited to electronic or e-cigarettes), cigars, pipes, or smokeless tobacco products within the past 12 months. PLEASE PLACE AN IN THE BOX THAT DESCRIBES YOUR TOBACCO USAGE. Tobacco User By electing this option, you are affirming that you are a Tobacco User. Not A Tobacco User By electing this option, you are affirming that you do not use tobacco products. I certify that the information provided is true and accurate, and I acknowledge that providing false information is grounds for disciplinary action up to and including termination. Employee or Spouse Signature: Date: