Transportation Claim Form
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1MAIL TO:
FAX TO:
TRANSPORTATION
PayFlex Systems USA, Inc.
PayFlex Systems USA, Inc.
P.O. Box 3039
(402) 231-4310
CLAIM FORM
Omaha, NE 68103-3039
(No Cover Page Required)
(800) 284-4885
Page 1 of ______
WAIT! Did you know that you can file this claim online? Login to and select File a Claim under Quick Links.
Do you need your account balance? After logging in, access your account balance via the Financial Center.
Employee Name ____________________________________ Member Number ___________________________
(This may be your SSN or employer assigned number)
Employer Name ____________________________________________________________________________
Note: To make an address change, please contact your HR/Benefits office. For security purposes, we cannot accept address changes directly.
Transportation Claims
You may submit your claim for reimbursement at the end of each month after the expense has been incurred. Attach a copy of the itemized bill from the provider
(if available) showing the amount of your expenses. The itemized statement should include the provider name and address; date the service was provided; a
description of the type of service provided; and the dollar amount. Note: You are only eligible for reimbursement up to the monthly limit as established by the
IRS.
Claims are subject to strict filing deadlines, you must submit documentation showing that you have incurred the expense in the timeframe established by the plan.
(Some exceptions may apply.) This can include used transit passes or vouchers and transit tickets. You can receive reimbursement with a completed and signed
claim form. Also, there are times when the service provider does not provide a receipt. In that case, you can receive reimbursement with a completed and signed
claim form.
Transportation (Mass Transit) Expenses
Although your benefits under the transportation plan are not
Eligible Expenses
Ineligible Expenses
subject to federal income tax (up to the statutory limits), they may
Subway
Carpool
be subject to state income tax in certain states. You should
consult your tax advisor with any questions you have about your
Commuter bus
Gas
specific tax situation.
Train
Mileage
Vanpool
Tolls
Fares (airplane, helicopter, limousine, taxi)
----- Complete all information below. The form must contain this information. Writing ‘See attached’ is not acceptable. -----
Transportation (Mass Transit) Expenses
Expense
From
Thru
Provider Name
Amount
Type
Date*
Date*
$
$
$
$
$
$
$
$
$
$
$
$
Total
$
0
I certify that I have actually incurred these eligible expenses. I understand that expense incurred means the service has been provided that
gave rise to the expense, regardless of when I am billed or charged for, or pay for the service. The expenses have not been reimbursed or are
not reimbursable from any other source. I understand that any amounts reimbursed may not be claimed on my or my spouse’s income tax
returns. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions.
Employee Signature
Date
_____________________________________________
__________________
*****Make copies for yourself, since these documents will not be returned. If you fax your claim, keep the original.*****
Rev. 6/2013
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