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I Gallaudet University Payroll Office College Hall, Room 320 SmartBenefits SmarTrip Ext. 5687 Election Form Personal Information Ms/Mrs/ IName Mr UF/MI SSN Email I Address ICheck Your Mode Of Transportation Metrorail Registered Van Pool Montgomery County Ride On Dash Martz Metrobus PRTC-Omni Ride National Coach Works CUE Other ART Fairfax Connector Loudon Commuter Bus Service D & B Bus/Quick's SmarTrio Card Information My SmarTrip card number is . Please attach a copy of your SmarTrip Card. SmarTrip card must be registered in applicant's name. If not, the application will not be processed. I elect to participate in the SmarTrip program for my personal commute to and from work by having pre-tax deductions taken from my biweekly paycheck to update the value of my SmarTrip account. The deduction will only be deducted on the 1 st and 2"d pay dates of the month; no deduction will be made on the 3rd pay date. The deduction will continue until I submit a cancellation form or until 11 am no longer in a pay status. If I am on Leave Without Pay; I understand my deduction will stop and I must complete a new election form when I return. I understand that once the deduction is taken from my paycheck, I will not receive a refund/credit; my SmarTrip account will be credited in the amount equal to my deduction and must be claimed and used within the month it is submitted to WMA TA. I understand that failure to follow this process will result in forfeiture of funds or any portion of the funds for any month that I do not make a claim and use all the credit that was given for the month. ALL FUNDS THAT ARE SENT TO WMATA MUST BE CLAIMED AND USED THAT MONTH. I have read and understand the contents of this form _ _ _ {initials) I elect to have the following amounts deducted from my biweekly paycheck for: Transit/Bus$__________ (IRS limit is $255.00 per month)* Parking at Metro Stations $__________ (WMATA's limit is $255.00 per month)* Total Amount Per Paycheck $ (1 st & 2"d pay of each month only) *Funds for transit/bus and parking will not be transferred from one section to another, only funds in your "personal section" can oav for either if vou should use vour monthlv amount uo before the end ofthe month. Signature: Date: I elect to cancel mv SmarTrip deduction beqinninq with the next pay period from submission of this form. Signature: Date: Per IRS regulations the total deduction for transit/bus benefits may not exceed $255.00 a month and $3,060.00 per year (deductions must be in whole dollar amounts). This is a maximum of $127.00 for SmarTrip (transit/bus benefits) per paycheck. WMATA policy limits the monthly deduction for Metro Parking Stations to $255.00 per month and $3060.00 per year (deduction must be in whole dollar amounts). This is a maximum of $127.00 for SmarTrip (Metro Parking benefits) per paycheck. SmarTrip deductions will only be deducted on the first and second pay of the month. Please do not request deductions beyond this limit or the Payroll Office will not process your form. Make a copy of this form for your records Last update 0 11201 6 .

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Sponsored by Arlington County
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