Fillable Dd2845-October2007 001 DD Form 2845, DoD NCR Mass Transportation Benefit Program Application, October 2007

Fill Online, Printable, Fillable, Blank Dd2845-October2007 001 DD Form 2845, DoD NCR Mass Transportation Benefit Program Application, October 2007 Form

Use Fill to complete blank online WASHINGTON HEADQUARTERS SERVICES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Dd2845-October2007 001 DD Form 2845, DoD NCR Mass Transportation Benefit Program Application, October 2007

On average this form takes 29 minutes to complete

The Dd2845-October2007 001 DD Form 2845, DoD NCR Mass Transportation Benefit Program Application, October 2007 form is 3 pages long and contains:

  • 0 signatures
  • 1 check-box
  • 115 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Washington Headquarters Services forms online.

BROWSE WASHINGTON HEADQUARTERS SERVICES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 5 U.S.C. 7905, Programs to Encourage Commuting by Means other than Single Occupancy Motor
Vehicles; 10 U.S.C. 131, Office of the Secretary of Defense; E.O. 12191, Federal Facility Ride Sharing Program, E.O. 13150, Federal Workplace
Transportation; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To manage the DoD NCR Mass Transportation Benefit Program including, but not limited to, evaluation and reimbursement of
participants, to track the allocated funds in support of the program and prevent misuse of those funds.
ROUTINE USE(S): To the Department of Transportation for the purposes of administering the program and/or verifying the eligibility of individuals to
receive a fare subsidy. Data may be provided under any of the DoD "Blanket Routine Uses".
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in disapproval of the Mass Transportation Benefit Program
Application.
PRIVACY ACT STATEMENT
DD FORM 2845, OCT 2007
GENERAL INSTRUCTIONS
1. Print or type information. Obsolete, incomplete, or illegible applications will not be processed.
2. Before applying, check the Qualifying information section below. Program policy, instructions, application form, and distribution site information is
available at: http://www.whs.mil/DFD/Info/NCRTransitSubsidy.cfm
.
3.
Check the website provided above to verify enrollment or call (703) 614-0084.
4. Once you verify enrollment, you may request benefits at a distribution site.
5. Counterintelligence Field Activity (CIFA), Defense Intelligence Agency (DIA), and National Security Agency (NSA) civilian employees must apply through
their respective agencies.
6. There is approximately a month waiting period between the receipt of this application and the availability of the benefit.
7. Upon completion, fax application to: (703) 614-4211.
To check the status of your application, please check the following website: http://www.whs.mil/DFD/Info/NCRTransitSubsidy.cfm or call: (703) 614-0084.
To qualify for this program, you must be:
(1) A civilian, military or NAF employee paid and employed by the Department of Defense, and
(2) Permanently stationed and working in the National Capital Region (NCR).
- Paid interns and summer hires in the NCR are eligible.
- Members of the Reserve Components who are performing active duty for more than 30 days are eligible.
The following are not eligible to receive the subsidy:
- Contractors
- Personnel that are TDY to the NCR from another area.
- Personnel that are on detail to the NCR from an area outside the NCR.
- Inactive reserve personnel
- Intergovernmental Personnel Act (IPA) employees (unless appointed to DoD).
- Foreign Exchange Employees.
QUALIFYING INFORMATION
Page 1 of 3 Pages
Adobe Professional 7.0
U.S. DEPARTMENT OF DEFENSE (NATIONAL CAPITAL REGION)
MASS TRANSPORTATION BENEFIT PROGRAM APPLICATION
1. IMPORTANT: To process this application, you must select one of the following. Are you (X only one):
WITHDRAWING
NEW ENROLLMENT
MAKING A CHANGE
RE-ENROLLING (X here if you have been
previously enrolled in the DoD NCR Program.)
2. EMPLOYEE CERTIFICATION
WARNING: This Certification concerns a matter within the jurisdiction of an agency of the United States and making a false, fictitious, or fraudulent
certification may render the maker subject to a criminal prosecution under Title 18, United States Code, Section 1001, Civil Penalty Action, providing for
administrative recoveries of up to $10,000 per violation, and/or agency disciplinary actions up to and including dismissal. Substantiated violations of any of
these certifications may impact an employee's security clearance status. Information provided on this form may be audited.
I certify that I understand that I am employed by the U.S. Department of Defense and am not named on a Federally subsidized workplace parking
permit with DoD or any other Federal agency. If applicable, I have relinquished my workplace parking permit to the issuing authority.
I certify that I understand that I am eligible for a public transportation fare benefit, will use it only for my daily commute to and from work, will not
transfer it to anyone else, and will not allow anyone else to use it.
I certify that I understand that the monthly transportation benefit I am receiving does not exceed my monthly commuting costs.
I certify that I understand that my claim for benefits is as a Federal employee and not as a contract employee.
I certify that I understand that I must adjust the amount received based upon long term TDY.
I certify that I understand that upon separation from DoD, I will return unused fare media to the MT representative. If I have converted the fare
media to another form of media, I will reimburse the DoD by check or money order payable to the U.S. Treasury.
I certify that I understand that I will notify the MTB office of any changes in my status, i.e., home or work address, change in commuting pattern, or
change in organization even if within the DoD.
PREVIOUS EDITION IS OBSOLETE.
MANDATORY: Read and initial each box. Sign and date Item 8 on Page 3 after completing form.
I certify that I understand that I will not calculate parking costs.
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.
EMPLOYEE SIGNATURE DATE SIGNED (YYYYMMDD)
Reset
DD FORM 2845, OCT 2007
3. APPLICANT INFORMATION
a. LAST NAME b. FIRST NAME c. MIDDLE INITIAL
d. RESIDENCE (City) e. STATE f. 9-DIGIT ZIP CODE*
m. ORGANIZATION CODE (Listed above) (Indicate the organization that employs you (i.e., pays your salary). Military personnel should indicate their branch of service,
not the Defense Component to which they are assigned.)
i. WORK TELEPHONE NUMBER
(Include Area Code)
g. LAST 4 DIGITS OF YOUR
SSN
q. ARE YOU ISSUED A FEDERALLY SUBSIDIZED PARKING PASS?
IF YES, WHERE DO YOU PARK?
CIVILIAN
MILITARY - ENLISTED
NON-APPROPRIATED FUNDS (NAF)
YES NO
OTHER (If not listed, specify):
n. TYPE OF EMPLOYEE: MILITARY PERSONNEL
o. OTHER TYPE OF EMPLOYEE: (X one only)
AIR FORCE
ARMY
NAVY
MARINE CORPS
OTHER:
p. FOR NAF FUNDING:
BRANCH OF SERVICE: (X one only)
h. WORK E-MAIL ADDRESS
RESERVIST - ENLISTED
j. DUTY STATION (the building where you report to work) (Street address) k. CITY l. 9-DIGIT ZIP CODE*
Page 2 of 3 Pages
*To find your 9-digit zip code, check http://zip4.usps.com/zip4/welcome.jsp
PAID TEMPORARY HIRE(Term of employment:
Start date/ End date)
ORGANIZATION CODES. Use these codes to complete Item 3.m., "Organization".
Headquarters Air Force
Field Operating Agency/
Direct Reporting Unit
CDC, MWR, BOQ, EXCHANGE
All other Air Force not listed
above
HAF
FOA/DRU
AF/NAF
Other/AF
U.S.
AIR FORCE
Headquarters, Department of the Army
Army Test and Evaluation Command
U.S. Army Materiel Command
U.S. Army Criminal Investigation Command
Defense Language Institute
Human Resources Command
U.S. Army Intelligence and Security
Command
Installation Management Command
Joint Chiefs of Staff - Army Employee
U.S. Army Medical Command/
The Surgeon General
U.S. Army Military District of Washington
HQDA
ATEC
AMC
CID
DLI
HRC
INSCOM
IMCOM
JCS/ARMY
MC/SG
MDW
U.S.
ARMY
11 N09BF
12 AAUSN
14 CNR
15 INTCOM
18 BUMED
19 NAVAIR
22 BUPERS
23 NAVSUP
24 NAVSEA
25 NAVFAC
30 SSP
U.S.
NAVY
Director, Field Support Activity - all OPNAV
Assistant for Administration, USECNAV
Chief of Naval Research
Director, Office of Naval Intelligence
Chief, Bureau of Medicine and Surgery
Commander, Naval Air Systems Command
Chief of Naval Personnel
Commander, Naval Supply Systems Command
Commander, Naval Sea Systems Command
Commander, Naval Facilities Engineering Command
Director, Strategic Systems Programs
27 HQMC
MC/NAF
Other/MC
Army/Air Force Exchange Service
American Forces Information Service
Defense Advanced Research Projects
Agency
Defense Acquisition University
(employees only)
Defense Business Transformation Agency
Defense Commissary Agency
Defense Contract Audit Agency
Defense Contract Management Agency
Defense Finance and Accounting Service
Defense Human Resources Activity
Defense Information Systems Agency
Defense Logistics Agency
AAFES
AFIS
DARPA
DAU
DBTA
DECA
DCAA
DCMA
DFAS
DHRA
DISA
DLA
U.S.
DEPARTMENT OF DEFENSE - COMPONENT
U.S. MARINE CORPS
Headquarters, Marine Corps
CDC, MWR, BOQ, EXCHANGE
All other Marine Corps not
listed above
National Defense University
(employees only)
Office of Economic Adjustment
Office of the Secretary of Defense
OSD/JS Welfare and Recreation
Association
Pentagon Force Protection Agency
Stars & Stripes
TRICARE Management Activity
Uniformed Services University of
the Health Sciences/Armed Forces
Radiobiology Research Institute
(employees only)
Washington Headquarters Services
NDU
OEA
OSD
OSD/JS
WRA
PFPA
STARS
TMA
USUHS/
AFRRI
WHS
33 MSC
39 SPAWAR
41 NSMA
52 CNI
60 LANTFLT
69 SECGRU
70 PACFLT
72 RESFOR
76 NETC
N/NAF
Other/NAVY
Military Sealift Command
Commander, Space and Naval Warfare Systems Command
Director, Naval Systems Management Activity
Commander Naval Installations
Commander in Chief, U.S. Atlantic Fleet
Commander, Naval Security Group Command
Commander in Chief, U.S. Pacific Fleet
Commander, Naval Reserve Force
Naval Education and Training Command
CDC, MWR, BOQ, Navy Exchange Lodge
All other Navy not listed above
Defense Legal Services Agency
DoD Concessions Committee
Defense Education Activity
Defense Office Inspector General
Defense POW/MP Office
Defense Security Cooperation Agency
Defense Security Service
Defense Technical Information Center
Defense Threat Reduction Agency
Defense Technology Security
Administration
Joint Chiefs of Staff
Missile Defense Agency
National Geospatial Intelligence Agency
DLSA
DoDCC
DODEA
DOD IG
DPMO
DSCA
DSS
DTIC
DTRA
DTSA
JCS
MDA
NGA
U.S. Army Network Command
Army National Guard
Office, Chief, Army Reserve
Office of the Secretary of Defense -
Army Employee
Surface Deployment and Distribution
Command
U.S. Army Space and Missile Defense
Command
U.S. Army Acquisition Support Center
U.S. Army Corps of Engineers
Walter Reed Army Medical Center
CDC, MWR, BOQ, EXCHANGE
All other Army not listed above
NETCOM
NGB
OCAR
OSD/ARMY
SDDC
SMDC
USAASC
USACE
WRAMC
A/NAF
Other/ARMY
MILITARY - OFFICER
RESERVIST - OFFICER
(1) STATUS: (X one only)
AIR FORCE
ARMY
NAVY
MARINE CORPS
(2) BRANCH: (X one only)
Reset
5. CONVERSIONS
a. DAILY COST TO MONTHLY
(1) DAILY MASS TRANSIT
COST
(2) NUMBER OF DAYS
COMMUTED PER MONTH
(3) TOTAL DAILY COST
PER MONTH
b. WEEKLY PASS TO MONTHLY
(1) WEEKLY PASS
COST
(2) NUMBER OF WEEKS
COMMUTED PER MONTH
(3) TOTAL WEEKLY
COST PER MONTH
c. TOTAL DAILY COST PER MONTH (If any)
d. TOTAL WEEKLY PASS COST PER MONTH (If any) e. TOTAL MONTHLY PASS COST PER MONTH (If any)
6. GRAND TOTAL COST PER MONTH
$
$
$
$
4. MASS TRANSPORTATION EXPENSE WORKSHEET
NOTE: DD Form 2845 application requires DoD subsidy participants to calculate their usual monthly mass transportation commuting cost. This worksheet
must be completed to receive subsidy benefits and will assist employees in computing their usual monthly mass transportation commuting cost to the
nearest dollar.
a. MODE OF TRANSPORTATION
b. DAILY EXPENSE
c. WEEKLY PASS
EXPENSE
d. MONTHLY PASS
EXPENSE
(1) BUS TO WORK (Local)
(2) BUS FROM WORK (Local)
(3) OTHER BUS MODE TO
WORK (Commuter or County)
(4) OTHER BUS MODE FROM
WORK (Commuter or County)
(5) RAIL TO WORK
(Light Rail or Subway)
(6) RAIL FROM WORK
(Light Rail or Subway)
(7) COMMUTER RAIL TO WORK
(Train)
(8) COMMUTER RAIL FROM
WORK (Train)
OTHER
(Specify)
(9) TO WORK
(10) FROM WORK
NAME OF COMPANY
NAME OF COMPANY
NAME OF COMPANY
NAME OF COMPANY
FROM WHAT STATION
FROM WHAT STATION
NAME OF COMPANY/STATION
NAME OF COMPANY/STATION
NAME OF COMPANY
NAME OF COMPANY
NAME OF COMPANY
(11) VAN POOL COST PER
MONTH
(12) TOTAL $ $ $
7. MY GRAND TOTAL MONTHLY MASS TRANSPORTATION COMMUTING COSTS
ROUNDED TO THE NEAREST DOLLAR
(Round either up or down to nearest dollar)
DD FORM 2845, OCT 2007
Page 3 of 3 Pages
9. THIS SECTION IS TO BE COMPLETED BY SUPERVISOR.
I confirm that the applicant is employed by the DoD, works at the duty station indicated, and has calculated the benefit based on the actual hours worked
(considering alternate work schedules, teleworking, etc.).
a. PRINTED OR TYPED NAME b. TITLE
c. TELEPHONE NUMBER (Incl. Area
Code)
d. SIGNATURE e. E-MAIL ADDRESS f. DATE SIGNED (YYYYMMDD)
a. EMPLOYEE SIGNATURE b. DATE SIGNED (YYYYMMDD)
8. EMPLOYEE. 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.
$
INSTRUCTIONS: Calculate your Total Monthly Mass Transportation Expenses by listing your mode of mass transportation and how much it costs you.
- Use the Daily
column if you pay for transportation on a daily basis,
- OR the Weekly
column if you purchase weekly commuter tickets;
- OR the Monthly
column if you purchase a monthly ticket or pass.
It is possible that you may list costs in more than one column depending on the number of transportation modes you take and how you pay for them. Then,
using the conversion section, convert all costs to monthly costs, to the nearest dollar amount.
- Applicants must calculate their monthly expenses based on the number of days commuted per month, taking into account telecommuting, alternate or
compressed work schedules, e.g., 17, 19, or 21 days per month.
REMEMBER: Parking fees are not allowed and cannot be included when computing monthly transit costs. If you are a person with a disability or a senior
citizen receiving reduced fare rates, you must calculate the reduced fare rates that you pay.
10. THIS SECTION IS TO BE COMPLETED BY AGENCY MASS TRANSPORTATION REVIEWING OFFICIAL.
I have reviewed this application and certify that employee is eligible to receive the mass transportation benefits.
a. PRINTED OR TYPED NAME b. TITLE
c. TELEPHONE NUMBER (Incl. Area
Code)
d. SIGNATURE e. E-MAIL ADDRESS f. DATE SIGNED (YYYYMMDD)
$ X $$X $
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0
Reset
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Dd2845-October2007 001 DD Form 2845, DoD NCR Mass Transportation Benefit Program Application, October 2007

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document