WWW.ASA.EDU
COMMUTER EXPENSE BENEFIT
2020 BENEFIT ELECTION FORM
PLEASE PRINT THE FOLLOWING INFORMATION
EMPLOYEE INFORMATION
Company Name:
Employee Name (Last, First): Social Security
Number:
Address:
City:
State: Zip:
E-Mail:
Daytime Phone:
Date of Birth:
Pay Cycle:
Weekly
Bi-Weekly
expenses. This money will be deducted from your pay before taxes are withheld, thus reducing your out-of-pocket costs for these expenses. You may
deposit up to $270.00 per month in your pre-tax reimbursement account for Parking Expenses. You may use your Flex Convenience card to pay for
these expenses at the time of purchase. Paper claims will be reimbursed twice a month. In addition you may also elect to contribute additional funds on
a Post-Tax basis which will be deducted from your pay after taxes are withheld.
Enter dollar amount to deposit per pay: $ _____________ = $ _____________ per month beginning ________________
Enter dollar amount to deposit per pay: $ _____________ = $ _____________ per month beginning ________________
PRE-TAX
POST-TAX
If you utilize the mass transit system such as the subway, ferry, train or bus to commute to work, you may elect to have a portion of your taxable salary
reducing your out-of-pocket costs for these expenses. You may deposit up to $270.00 per month in your Pre-Tax Reimbursement Account for Mass
Transit Expenses. You will be issued a Flex Convenience Card to pay for these expenses at the time of purchase. In addition you may also elect to
contribute additional funds on a Post-Tax basis which will be deducted from your pay after taxes are withheld.
Enter dollar amount to deposit per pay: $ _____________ = $ _____________ per month beginning ________________
Enter dollar amount to deposit per pay: $ _____________ = $ _____________ per month beginning ________________
PRE-TAX
POST-TAX
AUTHORIZATION
been posted to my account prior to my payroll deduction will need to be repaid to my employer at the time of my termination.
I understand that I must be able to provide receipt documentation upon request for any and all out-of-pocket expense costs as accessed through this
plan.
________________________________________
Employee Signature
________________________________________
Date
Non scholae, sed vitae discimus!
click to sign
signature
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