Fillable Parking Reimbursement Request printable pdf download

PARKING Reimbursement Request

PLEASE PRINT CLEARLY

CROSBY BENEFIT SYSTEMS

Employee

Information

Employee Name _____________________________________________________________________

Last

First

To update your address

or email, please login to

Employer ___________________________________________________________________________

Please enter your SSN or Employee ID. Many employers use an

Please also notify

SSN / Employee ID ______________________________

ID other than SSN with Crosby Benefit Systems. If you are unsure

employer of any

which number to use, please contact us or your HR/Benefits

address changes.

department. If you do not enter an SSN/Employee ID, Crosby will

attempt to identify you based on other information but this could

delay or prevent processing of your request.

Home Address _______________________________________________________________________

Street

City

State

Zip

Email Address _____________________________________

Home Phone (______)_____________________ Work Phone (______)_______________________

area code

ext.

Please list all parking expenses eligible for payment from your Parking Reimbursement Account. For expenses where a

Expenses

receipt was not available to you: Please certify the expense by initialing the space next to each amount listed

below.

Please note: The maximum monthly allowable reimbursement for parking is $250 per month.

PARKING

Date of Service*

Amount

Initial**

Date of Service*

Amount

Initial**

*The Date of

Service is the actual

date you parked,

_______________

$______________ ____

_______________

$_____________ ____

which may be

different from the

_______________

$______________ ____

_______________

$_____________ ____

day you paid for the

service.

_______________

$______________ ____

_______________

$_____________ ____

**For expenses

_______________

$______________ ____

_______________

$_____________ ____

where a receipt was

not available to you:

To the right, please

_______________

$______________ ____

_______________

$_____________ ____

certify the expense by

initialing the space

_______________

$______________ ____

_______________

$_____________ ____

next to the amount.

_______________

$______________ ____

_______________

$_____________ ____

_______________

$______________ ____

_______________

$_____________ ____

TOTAL EXPENSES $_____________

If available, submit receipts, canceled checks, statements or copies of punch cards, etc. with this form, showing

the service, by whom, the amount charged and the date. Retain a copy for your records.

Employee

I agree to hold my employer harmless if the Internal Revenue Service or any other tax agency challenges the nature of the payments

Certification

made under the program and agree to pay any taxes, interest and penalties that may be assessed concerning such payments. I will

reimburse my employer for my portion of any additional taxes that may be owed on my behalf should the Internal Revenue Service or any

other tax agency successfully challenges the characterization of the payments under the program. I hereby acknowledge that my

employer has made no representations or warranties to me whatsoever that the program will be qualified for tax purposes or that I will

receive the tax benefits I am seeking. I agree to abide by all of the terms and conditions of the Program.

Please

SIGN

Employee Signature ___________________________________________ Date __________________

Crosby Benefit Systems –866-918-9711 –Fax: 978-367-9626 –

P.O. Box 25172, Lehigh Valley, PA 18002-5172 - - version 0115

Parking Reimbursement Request

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