Qualified Parking Receipt Form - Justice Administrative Commission printable pdf download

Qualified Parking Receipt Form - Justice Administrative Commission

Justice Administrative Commission

Mail or Fax Completed Form To:

JAC QTB Plan Administrator

Qualified Transportation Benefit Program

PO Box 1654

Tallahassee, FL 32302

Qualified Parking Receipt Form

Toll Free Fax: 866-355-7906

Employee Name

Office/Circuit

To Be Completed by Parking Vendor

Vendor Name

Vendor Address

Tax ID (or FL Vendor #)

Garage/Lot Name

Location

Payment Coverage Dates

From

Amount

Vendor Certification

To the best of my knowledge, my statements in this Parking Receipt Form are complete and

true. I certify that the amount listed above was paid by the above named employee for his/her

own parking expense.

Vendor Signature __________________________________

Date ______________

Employee Certification

To the best of my knowledge and belief, my statements in this Parking Receipt Form are

complete and true. I certify that I have incurred the expenses described above on the dates

indicated, that the expenses qualify as valid expenses under the Plan, and that I have not

been reimbursed previously under any other benefit plan, nor do I expect any of these

expenses to be reimbursable elsewhere.

Employee Signature _______________________________

Date ____________

**This form must be submitted with the accompanying Employee Reimbursement for Parking

Form to be considered for reimbursement**

Qualified Parking Receipt Form - Justice Administrative Commission