Form Gsa 3667 - Application Form For Pretax Transportation Fringe Benefits - 2010
Download a blank fillable Form Gsa 3667 - Application Form For Pretax Transportation Fringe Benefits - 2010 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Gsa 3667 - Application Form For Pretax Transportation Fringe Benefits - 2010 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2APPLICATION FOR PRETAX TRANSPORTATION FRINGE BENEFITS
Processed by the National Payroll Branch (NPB)
PRIVACY ACT OF 1974
In compliance with the Privacy Act of 1974, the following information is provided: Basic authority for requiring the requested information is
contained in 5 USC 7905, 30 USC 905, Executive Order 9397, as amended by Executive Order 13478, and 26 USC 132. Disclosure of
the data by you is voluntary. The principal purpose for collecting the data is to determine your eligibility for and amount of reimbursement
to you for expenses incurred in commuting to and from work. Information provided is protected under GSA Privacy Act System Notice
GSA/-Transit-1 (Transportation Benefits Records). Information may be disclosed to appropriate Federal, State, or local agencies when
relevant to civil, criminal or regulatory investigations or prosecutions. There is no personal liability to you if you do not furnish the
requested information; however, you will not be reimbursed for your expenses.
BACKGROUND
26 CFR Parts 1 and 602 provide rules to ensure qualified transportation fringe benefits provided to employees are excludable from gross
income. These final regulations reflect changes to the law made by the Energy Policy Act of 1992, the Taxpayer Relief Act of 1997, and
the Transportation Equity Act for the 21st Century of 1998. The final regulations affect employers offering qualified transportation fringe
benefits and employees who receive these benefits.
1. EMPLOYEE INFORMATION
a. NAME
LAST
MIDDLE INITIAL
FIRST
b. FILING DATE
c. EFFECTIVE MONTH
d. REGION
e. AGENCY
2. TYPE OF BENEFIT
NOTE: RECERTIFICATION IS REQUIRED BY DECEMBER 15TH OF EACH YEAR,
OR WHEN AN EMPLOYEE'S CIRCUMSTANCES CHANGE
CHECK
MONTHLY PRETAX
TYPE
APPROPRIATE BOX
AMOUNT REQUESTED
a. Transportation in Commuter Highway Vehicle (Up to $230.00 Monthly)
A commuter highway vehicle must have a seating capacity of at least six
(6) adults, not including the driver. At least 80 percent of the mileage used
must be for purposes of transporting employees in conjunction with travel
between their homes and places of employment.
b. Transit Pass (Up to $230.00 - Monthly - Allowed only when your agency
doesn't provide mass transit passes)
A transit pass means any pass, token, fare card, voucher, or similar item
entitling a person to transportation, or transportation at a reduced price, if
such transportation is on mass transit facilities.
c. Qualified Parking (Up to $230.00 - Monthly)
The term "qualified parking" means parking is provided to an employee
either on or near the business premises of the employer, or on or near a
location from which the employee commutes to work by mass transit, in a
commuter highway vehicle or by carpool. Such term shall not include any
parking on or near property used by the employee for residential purposes.
EFFECTIVE MONTH
d. Cancellation
3. CERTIFICATION
I hereby certify I am eligible for a transit benefit under 26 USC 132. I will be using the benefit exclusively for my regular daily direct
commute from home to work and return. I will not give, sell, barter, exchange, convey, or otherwise transfer it to any other person. The
monthly transit benefit I receive does not exceed my average monthly commuting cost based on a 20-day month commuting by public
transportation or eligible vanpool. I understand and agree that false certification may result in disciplinary action by the General Services
Administration up to and including dismissal from Federal employment and possible prosecution for Federal income tax evasion.
a. SIGNATURE OF EMPLOYEE
b. DATE
GENERAL SERVICES ADMINISTRATION
GSA 3667 (REV. 12/2010)
Sensitive, but Unclassified
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application Form For The Transportation Of Wood Processing Residue From July 1, 2000 To June 30, 2001 - Sawmill Biomass Credit
Financial
Form Doh-3667 - Application To Department Of Health For Copy Of Fetal Death Record - New York State Department Of Health Vital Records Section
Legal
Related Categories
Parent category: Financial