Payroll Deduction Authorization For Pre-Tax Commute Benefit Form

ADVERTISEMENT

SAMPLE FORM
The attached form may or may not meet your company's specific needs. Employers are encouraged to consult a tax advisor or
other professional for detailed information regarding the tax implications of commute benefits and incentives. Qualified
transportation benefits are governed by 26 USC Section 132(f).
PAYROLL DEDUCTION AUTHORIZATION
for PRE-TAX Commute Benefit
I hereby authorize my employer to deduct this amount from my
monthly wages on a pre-tax basis to be used on my behalf for
the purchase of bus, train, ferry or monthly vanpool fare to be
$__________*
1
loaded to an ORCA business card provided by my employer.
*Not to exceed $230 per month per 2010 IRS regulations
Employee Ordering options - check one:
(List only those items your company is willing to order for employees. ORCA requires setting up an ORCA Business Choice
Account)
ORCA Business Card Reloads
ORCA reload of monthly pass in the amount shown above.
ORCA reload of monthly vanpool/transit combo (good only for Metro vanpools and
buses) with cost equal to amount shown above (must be either $81 or $99)
ORCA reload for monthly ferry pass in the amount shown above.
ORCA E-purse deposit (on ORCA business-provided card only)
See ORCA Business Products list at:
Employee statement
I agree to notify payroll in writing by the _______ day of the month to cancel this arrangement for a pass
valid the following month. I understand that money deducted cannot be refunded.
I will be using this benefit for my regular daily direct commute from home to work and return. I will not
give, barter, exchange, convey, or otherwise transfer this benefit to any other person.
Signed Name: ___________________________________ Date:____________
Printed Name:____________________________________
1
Pre-purchased, individually owned ORCA cards may not be used for this benefit except Reduced Fare
cards purchased by seniors or disabled persons.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go