Employee Pre-Tax Parking Waiver Form - Oregon Department Of Administrative Services
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1Fleet & Parking Services
1100 Airport Rd SE
STATE OF OREGON
Salem, OR 97301-6082
503-378-5090
Employee Pre-Tax Parking Waiver Form
503-378-2157 fax
state.parking@oregon.gov
Employee Name
Employee ID#
Last
First
MI
(Non-state employees, enter last 4 digits of SS #)
Agency Name
Agency Number
Division/Section
Worksite Address
Street/City/Zip
Work Phone
Email
For events & issues relative to your assignment
YOUR VEHICLE DESCRIPTIONS:
Vehicle #1 – Year/Make/Model
State
Plate
Vehicle #2 – Year/Make/Model
State
Plate
Vehicle #3 – Year/Make/Model
State
Plate
☐ I elect to waive the opportunity to participate in the Pre-Tax Parking Plan. I understand that by not participating in the Plan,
any cost I am required to pay for my parking through payroll deductions will be made after all applicable federal and state taxes
have been withheld.
I understand that parking regulated by the Department of Administrative Services is subject to the provisions of OAR Chapter
125, and ORS Chapters 98, 276, 283, and 292. By accepting a parking assignment made by the Department, I agree to abide
by these rules and laws. I further understand that failure to abide by these rules and laws may result in citation, prosecution
and/or loss of parking privileges.
Signature
Date
FOR OFFICE USE ONLY
Lot assigned, space/permit number ______________________________
Monthly rate PKXN_____________
Effective date ________________________________________________
Payroll notification _________________
U:\PKG\Forms\PreTaxApplication.docx
Updated 8/29/2017 ICD
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