Pre-tax Benefit Program Commuter Choice Payroll Deduction Authorization

This directory contains information about voucher (*) and employer pass programs available in various cities (including the thirty largest transit agencies) throughout the United States. It includes the major transit agencies that offer such programs. However, due to the recent changes in the tax code, more transit agencies will likely begin similar programs. Therefore, do not use this list exclusively to determine whether or not such programs exist. If your city is not listed here, then please contact your local transit agency for information on passes and vouchers that might be available. Many transit agencies are listed on the Web at: [www.fta.dot.gov] or [http://www.apta.com/].

The information below is subject to change without notice and is current as of April 2002.

Pre-tax Benefit Program Commuter Choice Payroll Deduction Authorization

I hereby authorize my employer to deduct $ _____ from my monthly wages on a pre-tax basis, not to exceed $65 per month to be used for the purchase of a (select one):

I will be using the benefit exclusively for my regular daily direct commute from home to work and return. I will not give, barter, exchange, convey, or otherwise transfer this benefit to any other person. If I selected any of the first four choices, the monthly benefit that I receive does not exceed my average monthly commuting cost based on a 20 day month commuting by public transportation or eligible vanpool.  

I understand and agree that false certification may result in disciplinary action taken by my employer up to and including dismissal from employment and possible prosecution for Federal income tax evasion.

Signed: ___________________________ Date: ______________