Annual Premium Transitchek Metrocard Enrollment Form - New York City Health And Hospitals Corporation
ADVERTISEMENT
1NEW YORK CITY HEALTH AND HOSPITALS CORPORATION
TRANSIT BENEFIT PROGRAM
ANNUAL PREMIUM TRANSITCHEK METROCARD ENROLLMENT FORM
IMPORTANT INFORMATION FOR EMPLOYEES:
Your unlimited ride Annual Premium TransitChek Metrocard is provided as a pre-tax benefit contingent upon continuing
deductions from your gross pay. Your taxable wages reported to the IRS at the end of the year will be reduced by the total
amount of your Annual Premium TransitChek Metrocard deduction and increased by the value of the administrative fee paid
by HHC to the provider of the Annual Premium TransitChek Metrocard for each payday that you have a Transit Benefit
deduction.
INSTRUCTIONS:
TO ENROLL: Fill out sections 1 and 2. Make sure you sign the Address Certification and the Employer Authorization
TO TERMINATE YOUR PARTICIPATION: Fill out Sections 1 and 3.
SECTION 1: EMPLOYEE ENROLLMENT INFORMATION
EMPLOYMENT ID NUMBER:
NAME:
_______/______/_______
______________________________________________________________
LAST
FIRST
MI
FACILITY:
WORK TELEPHONE NUMBER:
______________________________________________
__(______)_____________________
… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … …
HOME ADDRESS
: (This is the address to which your Annual Premium TransitChek Metrocard will be mailed. Please make sure the address is correct.)
____________________________________________________________________________________________________
STREET NUMBER
APT.
____________________________________________________________________________________________________
CITY
STATE
ZIP CODE + 4
… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ..
ADDRESS CERTIFICATION:
I certify that the above address is my current home address. I understand that if the above address does not match
the address in HHC’ s Personnel and Payroll records, such records will be corrected to reflect the above address as
my current home address.
____________________________________
EMPLOYEE SIGNATURE
SECTION 2:
EMPLOYEE AUTHORIZATION
I understand that the use of my Annual Premium TransitChek Metrocard is contingent upon continuing deductions from my
gross pay and that, if for any reason, such deductions stop, my Annual Premium TransitChek Metrocard will be de-activated. I
understand that if my Annual Premium TransitChek Metrocard is lost or stolen, it will be replaced with one that will be active as
of the first day of the month following the month during which the lost or stolen Annual Premium TransitChek Metrocard was
active.
EMPLOYEE SIGNATURE: ___________________________________
DATE: ________________________________
SECTION 3:
TERMINATION OF SERVICE REQUEST
I hereby request the New York City Health and Hospitals Corporation terminate my enrollment in the Annual Premium
TransitChek Metrocard Program as soon as administratively possible.
EMPLOYEE SIGNATURE: ___________________________________
DATE: ________________________________
FOR FACILITY PAYROLL DEPARTMENT USE ONLY
ENROLLMENT REJECTION:
ENTRY INFORMATION:
NON-ELIGIBILITY
ENTERED BY:
DATE:
W1/B2 payee
Other – List reason below
________________________
____/____/____
Not covered
Reason: ________________________
by City-Wide
_______________________________
Eff. Payroll _____/____/____
Agreement
Informed employee of rejection
Name: ____________________________
Date: ______/____/_____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Dmna Form 04 - Annual/personal Day Leave Request Form - New York State Military And Naval Affairs
Legal
Form Mt-53 - Schedule E New York City Beer And Similar Fermented Malt Beverages - New York State Department Of Taxation And Finance
Financial
Form Wic-48 - Louisiana Women, Infant And Children (wic) Special Supplemental Nutrition Program Form - Louisiana Department Of Health And Hospitals
Legal
Related Categories
Parent category: Legal