Effective Date 1 October 2010
ARMY MASS TRANSPORTATION BENEFIT PROGRAM
Outside the National Capital Region
Please check one:
Change Request (what change?)
Withdrawing (effective date)
I. Applicant Information:
Last Four SSN:
Residence 9-digit ZIP Code:
Duty Location (city, state, 9-digit ZIP code):
Office Telephone (include area code):
Supervisor Name, Location, Office Telephone (include area code):
Employment type (please check only one):
Army Active Duty Officer
Army National Guard Active Duty Officer
Army Reserve Active Duty Officer
Army Active Duty Enlisted
Army National Guard Active Duty Enlisted
Army Reserve Active Duty Enlisted
Army Civilian Employee
Army National Guard Civilian/Mil Tech Employee
Army Reserve Civilian Employee
Army Nonappropriated Fund Employee - Please provide 9-digit Standard NAFI Number:
II. Applicant Certification: Please read and initial each item.
I certify that I understand that I am employed by the U.S. Department of the Army as a military member, civilian
employee or non-appropriated fund employee. My claim for benefits is as a Federal employee or military service
member, and not as a contract employee.
I certify that I understand that I am eligible for a public transportation fare benefit, will only use it for my daily
commute to and from work, will not transfer it to anyone else, and will not allow anyone else to use it.
I certify that I understand that the mode of transportation for which I am claiming the mass transportation
benefit is a qualified means of transportation.
I certify that I understand that the monthly transportation benefit I am claiming does not exceed my monthly
I certify that I understand that I will not include parking costs, tolls, or the cost of "holding" a space in a vanpool
when calculating and claiming my monthly commuting costs.
I certify that I understand that I will adjust the amount received based upon extended absence (e.g. leave, TDY or
I certify that I understand that I will notify my local MTBP Program Manager of any changes in my status, e.g.
name change, home or work address, change in commuting pattern or cost, or change in duty location or
employing organization, even if within the Army.
I certify that I understand that upon separation from the MTPB, I will return unused fare media to my local MTBP
Program Manager. If I have used the fare media for other purposes or converted the fare media to another form
of media, I will reimburse the Army by check or money order payable to the U.S. Treasury.