Qualified Parking And Transportation Reimbursement Program Request Form - Benefit Advantage
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1Mail: PO Box 5546 DePere, WI 54115-5546
Phone: (800) 686-6829
Fax: (920) 339-0038
Company Name:_______________________
Qualified Parking and Transportation
Reimbursement Program Request Form
Last
First
NAME:
SSN#:
ADDRESS:
PHONE: (
)
Please check if this is a new address.
Instructions: Be sure to provide All information requested by this Form. If the form is
incomplete, it will be returned to you. Please date and sign the Form, then send it along
with your supporting documentation to Benefit Advantage.
Benefit Type
Dates Service
Total of
Proof of
Reimbursement
Please select one
Provided
Expense
Expense
Requested
benefit per line
Attached
$
$
Transit
Yes
Parking
No
$
$
Transit
Yes
Parking
No
$
$
Transit
Yes
Parking
No
$
$
Transit
Yes
Parking
No
$
$
Transit
Yes
Parking
No
Total
$
Reimbursement
Requested
*There is a $25.00 minimum check amount.
EMPLOYEE’S CERTIFICATION FOR REIMBURSEMENT
To the best of my knowledge and belief, my statements on this Form are complete and true. I certify all of the
following. I used the Transportation Benefit for which I am requesting reimbursement above only for purposes of
commuting to and from work at the Employer. I have received the services described above on the dates indicated,
and the expenses are my out-of-pocket expenses that qualify as valid Transportation Expenses under the Plan. I
have not been reimbursed previously for these expenses under The Plan. These expenses have not been reimbursed
or are not reimbursable under any other plan. I understand that the expenses reimbursed under the any other plan. I
authorized a deduction in my Transportation Account in the amount of the reimbursement.
__________________________________________________
______________________
Employee Signature
Date
FAX TO (920) 339-0038 OR (920) 339-5736
OR MAIL TO: BENEFIT ADVANTAGE, INC.
PO BOX 5546, DE PERE, WI 54115-5546
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