Army Mass Transportation Benefit Program Outside The National Capital Region Application Form Page 2
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3III. Mass Transportation Benefit Calculation:
Mass Transportation system(s) or company(s) you intend to use:
Specific type(s) of fare media you require:
Type of benefit requested (check one):
DOT-issued fare media
SF 1164 reimbursement - If SF 1164, please complete Part IV.
Describe your commute from home to work and
back when using mass transportation. See
example on the Instruction page.
A. Your Work Schedule: Enter the NUMBER OF WORKDAYS PER MONTH:
A. NUMBER OF WORKDAYS PER MONTH:
If you work 8 hour workdays, 40 hours per week - enter 21
If you work 9 hour compressed workdays, 40 hours per week - enter 19
If you work10 hour compressed workdays, 40 hours per week - enter 17
If you work another schedule - enter the number of days you work per month
B. Do you work at home some days?
B. WORKING FROM HOME:
If YES, enter the number of days per month you work at home
If NO, enter Zero
C. Do you work at a Telecommuting location some days?
C. WORKING AT TELECOMMUTING SITE:
If YES, and if you DO NOT use public transportation to get there, enter the
number of days per month
If YES, but you DO use public transportation to get there, enter Zero
If NO, enter Zero
D. Total number of days per month mass transportation may be used:
D. TOTAL COMMUTING DAYS (A - B - C):
Daily Cost
Line D
Monthly Cost
E. DAILY Commuting Cost (use only if you pay a daily fare):
X
=
Weekly Cost
Monthly Cost
X
4
F. WEEKLY Commuting Cost (use only if weekly pass/voucher is available):
=
Monthly Cost
G. MONTHLY Commuting Cost (use only if monthly pass/voucher is available):
Enter the lesser of E, F, or G. THIS IS YOUR CLAIMED MONTHLY COMMUTING COST PER PERSON.
As of 1 January 2013, the maximum benefit amount available to Federal employees for actual commuting costs is
$245 per month. For Army participants, this increase takes effect as of 1 May 2013.
IV. Funding Information (SF 1164 users only):
Please provide the accounting classification that funds your salary:
V. Signature and Review:
APPLICANT: I certify that the above information is true and correct. I further acknowledge that any false statements or
misrepresentations made by me for the purposes of my certification for this benefit may subject me to criminal, civil,or
administrative penalties.
APPLICANT SIGNATURE: ___________________________________________________________ DATE: _____________________
SUPERVISOR: I certify that I am the supervisor of this employee, and that he/she is eligible for the program as an Army civilian
employee, military member, or NAF employee. The employee works at the duty station indicated, and has calculated the benefit
based on the actual hours worked (considering alternate work schedules, teleworking, etc.).
SUPERVISOR SIGNATURE: __________________________________________________________ DATE: _____________________
POC REVIEW/APPROVAL: __________________________________________________________ DATE: _____________________
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