Salary Reduction Authorization

SmartBenefits Salary Reduction Authorization

Form must be submitted to the Office of Human Resources by the 14th of the month in order to receive your benefit for the following month!

Name: Empl ID: Campus Address: Extension: School or Department:

Effective Date of SmartBenefits Participation or Date of Change: WMATA Registered SmarTrip card serial # (Look on back of card in the lower right hand corner):

Remember, you must register your SmarTrip card on www.wmata.com prior to filling out this form! Benefits will not be added for anyone that has not registered their card.

Beginning January 1, 2013 the monthly limitation under 132(f)(2)(A), regarding the aggregate fringe benefit exclusion amount for transportation in a commuter highway vehicle and any transit pass is $240. The monthly limitation under 132(f)(2)(B), regarding the fringe benefit exclusion amount for qualified parking is $240.

CUA has established a $240 maximum per month for transit & $240 for parking.

The types of public transportation that are included in the SmartBenefit Program are Metrorail, Metro bus, VRE, MARC Train, commuter bus lines (such as Dillon, Eyre, Keller, PRTC, etc.) and County buses (such as Ride-on, Connector, Dash, etc.). If you are using MARC or VRE, please contact Commuter Direct www.commuterdirect.com to set up an account.

I certify that I regularly use one of the preceding types of public transportation or a commercial vanpool or bus service to commute from home to work. My monthly cost to commute to work on the type of public transportation listed above (based on an average of 22 workdays per month) is $ .

I request that the University withhold $ for transit. I request that the University withhold $ ______for parking. Total Amount Requested $______

I understand that any changes in participation or the amount of withholding can only be made on a monthly basis.

Revised January 3, 2013 Employee Signature Date

Revised January 3, 2013