Fillable Army Mass Transportation Benefit Program Application Form (Page 2 of 3) in pdf

Army Mass Transportation Benefit Program Application Form Page 2

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III. Mass Transportation Benefit Calculation:

Mass Transportation system(s) or company(s) you intend to use:

Specific type(s) of fare media you require:

Type of benefit requested (check one):

DOT-issued fare media

SF 1164 reimbursement - If SF 1164, please complete Part III.

Describe your commute from home to work and

back. See example on the Instruction page.

A. Your Work Schedule: Enter the NUMBER OF WORKDAYS PER MONTH:

A. NUMBER OF WORKDAYS PER MONTH:

If you work 8 hour workdays, 40 hours per week - enter 21

If you work 9 hour compressed workdays, 40 hours per week - enter 19

If you work10 hour compressed workdays, 40 hours per week - enter 17

If you work another schedule - enter the number of days you work per month

B. Do you work at home some days?

B. WORKING FROM HOME:

If YES, enter the number of days per month you work at home

If NO, enter Zero

C. Do you work at a Telecommuting location some days?

C. WORKING AT TELECOMMUTING SITE:

If YES, and if you DO NOT use public transportation to get there, enter the

number of days per month

If YES, but you DO use public transportation to get there, enter Zero

If NO, enter Zero

TOTAL COMMUTING DAYS (A - B - C):

Enter DAILY commuting cost (use if you pay a daily fare)

D. Monthly Commuting Cost (Daily Cost x Total Commuting Days)

Enter WEEKLY commuting cost (use only if weekly pass/voucher is available)

E. Monthly Commuting Cost (weekly cost x 4)

F. Enter MONTHLY commuting cost (use only if monthly pass/voucher is available)

Enter the lesser of D, E, or F. THIS IS YOUR CLAIMED COMMUTING COST.

As of 1 January 2010, the maximum benefit amount available to Federal employees for actual commuting costs is

$230 per month ($2,760 per year).

IV. Funding Information (SF 1164 users only):

Please provide the accounting classification that funds your salary:

V. Signature and Reveiw:

APPLICANT: I certify that the above information is true and correct. I further acknowledge that any false statements or

misrepresentations made by me for the purposes of my certification for this benefit may subject me to criminal, civil,or

administrative penalties.

APPLICANT SIGNATURE: ___________________________________________________________ DATE: _____________________

SUPERVISOR: I certify that I am the supervisor of this employee, and that he/she is eligible for the program as a civilian employee,

military member, or NAF employee. The information provided is true and correct to the best of my knowledge.

SUPERVISOR SIGNATURE: __________________________________________________________ DATE: _____________________

POC REVIEW/APPROVAL: __________________________________________________________ DATE: _____________________

Army Mass Transportation Benefit Program Application Form Page 2

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