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UNITED STATES AIR FORCE

OUTSIDE THE NATIONAL CAPITAL REGION

PUBLIC TRANSPORTATION BENEFIT PROGRAM APPLICATION

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

Withdrawing

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____________________

PRIVACY ACT STATEMENT:

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.