Payroll Deduction Authorization For Pre-Tax Commute Benefit Form printable pdf download

SAMPLE FORM

The attached form may or may not meet your company's specific needs. Employers are encouraged to consult a tax advisor or

other professional for detailed information regarding the tax implications of commute benefits and incentives. Qualified

transportation benefits are governed by 26 USC Section 132(f).

PAYROLL DEDUCTION AUTHORIZATION

for Pre-Tax Commute Benefit

Actual cost of my monthly transit pass for bus, train, ferry or monthly

$__________

vanpool fare.

Amount the company contributes to monthly cost of transportation

- $_________*

I hereby authorize my employer to deduct this amount from my

monthly wages on a pre-tax basis to be used on my behalf for the

purchase of bus, train, ferry or monthly vanpool fare to be loaded to

=$_________*

an ORCA business account card provided by my employer.

*Not to exceed $230 per month per 2010 IRS regulations

Employee Ordering options - check one:

(List only those items your company is willing to order for employees. ORCA requires setting up an ORCA Business Choice

account.)

ORCA Business Card Reloads

ORCA monthly Puget Pass in the amount shown in A above.

ORCA monthly vanpool/transit combo (good only for Metro vanpools and buses) in the amount

shown in A above.

ORCA monthly ferry pass in the amount shown in A above.

ORCA E-purse deposit for the amount shown in A above. Card will not accept more than $300

accumulated funds.



See ORCA Business Products list at:

Employee statement

I agree to notify payroll in writing by the _______ day of the month to cancel this arrangement for a pass

valid the following month. I understand that money deducted cannot be refunded.

I will be using this benefit for my regular daily direct commute from home to work and return. I will not give,

barter, exchange, convey, or otherwise transfer this benefit to any other person..

Signed Name: ___________________________________ Date:____________

Printed Name:___________________________________

Pre-purchased, individually owned ORCA cards may not be used for this benefit except Reduced Fare

cards purchased by seniors or disabled persons.

Payroll Deduction Authorization For Pre-Tax Commute Benefit Form