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The covered employee must complete this form and return to Human Resources. Tobacco cessation represents the single most important step tobacco users can take to enhance the length and quality of their lives. Ogden City is committed to providing a health care premium reduction for employees who are tobacco free, as well as support to all employees who wish to stop using tobacco products. The goal of this program is to recognize employees for healthy lifestyles and engagement in their health. This Tobacco-Free Affidavit must be completed by you, the employee, within your fist 6 months of employment in order to continue to receive the reduction in your 2017 – 2018 medical contribution. Your medical plan contribution will be reduced each month if you certify you are tobacco free. Individuals are considered to be a tobacco user if they use any form of tobacco products including but not limited to: cigarettes, cigars, pipes, e-cigarettes, dipping, chewing tobacco, snuff and/or inhaled products. Employees who currently use tobacco products may choose to actively participate in our company approved tobacco cessation program (TCP) to receive the premium reduction. Employees who choose to participate in the TCP will have access to tools, trackers, and Nicotine Replacement Therapy (NRT) to help them achieve optimal cessation outcomes. This program is provided at no cost and is entirely optional. To register for the TCP please select the, “I USE tobacco but will complete the cessation plan” option below. For additional information contact Heidi Olmedo at ext. [PHONE REDACTED]: Tobacco-Free Affidavit By checking below, I affirm I have read and understand the information in this affidavit and I am making this affirmation in order to receive the 2017 – 2018 reduced medical rates for being tobacco-free. I understand that if I begin use of tobacco during the year, I am no longer eligible for the premium reduction and must report this change to Human Resources immediately. I understand that tobacco includes any form of tobacco products that are smoked (cigarettes, cigars, pipes, electronic cigarettes), applied to the gums (dipping, chewing tobacco, or snuff), and/or inhaled. I understand that if I intentionally falsify this affidavit or fail to report the commencement of tobacco use after completing this affidavit, I will be in violation of Section 9-6 of the Ogden City Employee Policy Manual and may be subject to disciplinary action, up to and including termination from employment. Employee I do not and/or will not use tobacco products during the 2017-2018 plan year. I currently use tobacco products and will participate in the approved Tobacco Cessation Program. I currently use tobacco products and will pay the higher premium. Employee’s Name (printed): Employee’s Signature: Date: 2 0 1 7 - 2 0 1 8 P l a n Y e a r O g d e n C i t y C o r p . T o b a c c o - F r e e A f f i d a v i t