Public Transportation Benefit Program Application - United States Air Force Outside The National Capital Region


Purpose: Executive Order 13150 requires Federal agencies to establish transportation incentive program in order to reduce Federal
employee’s contribution to traffic congestion and air pollution and to expand their commuting alternatives. The purpose of the
program is to encourage commuting by mass transportation and provide incentives to members/employee.
Applicant Information: Application must be filled out completely. Please print clearly as incomplete or illegible applications will
not be processed.
Application (please circle one): Enrolling
Making a Change
Name as it appears in payroll records or on paycheck:
Last Name: ______________________ First Name: ____________________ MI: ______ SSN (Last Four): ____________
City (Residence): __________________________State: _______________ Zip Code: ________________
Air Force Installation/Activity:_________________
Duty Location (City): _______________________
Office Telephone Number (Commercial): (___)____________________
Are you (circle one):
Air Force Active Duty
Air National Guard Active Duty
Air Force Reserve Active Duty
Air Force Civilian Employee
Air National Guard Civilian Employee
Air Force Reserve Civilian Employee
Air Force NAF Employee
Air National Guard NAF Employee
Air Force Reserve NAF Employee
Name of the transportation system/company used. ______________________________________________________________
What type of pass/ticket do you use?
Please Provide your SmarTrip Card Number:
B. Employee Certification:
WARNING: This certification concerns a matter with the jurisdiction of an agency of the United States and making a false, fictitious,
or fraudulent certification may render the maker subject to criminal prosecution under Title 18, United States Code, Section 1001, Civil
Penalty Action, providing for administrative recoveries of up to $10,000 per violation, and/or agency disciplinary actions up to and
including dismissal.
I certify that I am eligible for a public transportation fare benefit, will use it for my daily commute to and from work, and will
not transfer it to anyone else.
I certify that the monthly transit benefit I am receiving does not exceed my monthly commuting costs.
I certify that my usual monthly commuting costs are: $________
I certify that this information is accurate and agree to notify the installations POC of any change to employee status.
[Note: The current maximum benefit amount available to Air Force employees is $230.00 a month ($2,760.00 a year)].
Please indicate your estimated transportation cost above. Benefits will be paid in the form of transportation vouchers
wherever possible.
Employee Signature: _____________________________________________Date: _______________
Supervisor Signature: ____________________________________________ Date: _______________
C. Installation Point of Contact:
Name (Last, First):__________________________________________________Signature:_________________________________
Unit Address: ______________________________________________________________________Phone____________________
This information is solicited under authority of Public Law 101-509. Furnishing the information on this form is voluntary,
but failure to do so may result in disapproval of your request for the mass transportation fringe benefit. The purpose of this information is to facilitate timely processing
of your request, to ensure your eligibility, and to prevent misuse of the funds involved. This information will be matched with lists at other Federal agencies to ensure
that you are not listed as a carpool or vanpool participant or a holder of any other form of vehicle worksite parking permit with DoD or any other Federal agency.
Partial social security number (SSN - last four numbers) will be used for record keeping purposes.


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