NEW YORK CITY HEALTH + HOSPITALS
TRANSIT BENEFIT PROGRAM
ANNUAL PREMIUM TRANSITCHEK METROCARD ENROLLMENT FORM
IMPORTANT INFORMATION FOR EMPLOYEES:
Your unlimited ride Annual Premium TransitChek Metrocard is provided as a pre-tax benefit contingent upon continuing
deductions from your gross pay. Your taxable wages reported to the IRS at the end of the year will be reduced by the total
amount of your Annual Premium TransitChek Metrocard deduction and increased by the value of the administrative fee paid
by H+H to the provider of the Annual Premium TransitChek Metrocard for each payday that you have a Transit Benefit
TO ENROLL: Fill out sections 1 and 2. Make sure you sign the Address Certification and the Employer Authorization
TO TERMINATE YOUR PARTICIPATION: Fill out Sections 1 and 3.
SECTION 1: EMPLOYEE ENROLLMENT INFORMATION
EMPLOYMENT ID NUMBER: NAME:
LAST FIRST MI
FACILITY: WORK TELEPHONE NUMBER:
( )
……………………………………………………………………………………………………………………………………………………
HOME ADDRESS: (This is the address to which your Annual Premium TransitChek Metrocard will be mailed. Please make sure the address is correct.)
STREET NUMBER APT.
CITY STATE
ZIP CODE + 4
……………………………………………………………………………………………………………………………………………………………………………………..
ADDRESS CERTIFICATION:
I certify that the above address is my current home address.
EMPLOYEE SIGNATURE
*Please log into Employee Self Service if you need to update or view your current address on file.
SECTION 2: EMPLOYEE AUTHORIZATION
I understand that the use of my Annual Premium TransitChek Metrocard is contingent upon continuing deductions from my
gross pay and that, if for any reason, such deductions stop, my Annual Premium TransitChek Metrocard will be de -activated. I
understand that if my Annual Premium TransitChek Metrocard is lost or stolen, it will be replaced with one that will be active as
of the first day of the month following the month during which the lost or stolen Annual Premium TransitChek Metrocard was
active.
EMPLOYEE SIGNATURE: DATE:
SECTION 3: TERMINATION OF SERVICE REQUEST
I hereby request New York City Health + Hospitals terminate my enrollment in the Annual Premium TransitChek
Metrocard Program as soon as administratively possible.
EMPLOYEE SIGNATURE: DATE:
FOR FACILITY PAYROLL DEPARTMENT USE ONLY
ENROLLMENT REJECTION: ENTRY INFORMATION:
NON-ELIGIBILITY ENTERED BY: DATE:
/ /
Other – List reason below
Reason:
Informed employee of rejection
Eff. Payroll / /
Name: _
as of April 2020
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