NEWYORKCITYHEALTH+HOSPITALS
WAGEWORKSPROGRAMFORM
(SubmitcompletedformtoyourFacility'sPayrollDepartment)
CHANGEPERSONALINFORMATION
CHANGEPLANORDEDUCTION ADDORDELETEAPLAN SUSPENDDEDUCTION TERMINATEPARTICIPATION
Changee‐mailaddress
Changeplansand/ordeduction
amount
(checkone)
Addaplan
Deletea
p
lan
Temporarilystopdeductions
Inwhichplan:____________
Cancelparticipationinthe
programcompletely
EMPLOYEEID
EMAILADDRESS
HOMEADDRESS
CITY,STATE,ZIP
(A)PLAN
TYPE
(B)
PLANNAME
(C)
DEDUCTIONAMOUNTPERPAYCHECK
INPUTHEREIFYOUAREPAID
WEEKLY(48
deductions/yr)
(D)
DEDUCTIONAMOUNT
PERPAYCHECK
INPUTHEREIFYOUARE
PAIDBIWEEKLY
(24deductions/yr)
(E)
MONTHLYADMINISTRATIVEFEE
(F)
EMPLOYEEINITIALS
TRANSITPLAN1 COMMUTERCARD‐NOADMINFEE
CURRENTLY
$31.75
CURRENTLY
$63.50
$1.77ADDEDTOEARNINGSAS
TAXABLEFRINGEBENEFIT
TRANSITPLAN2 COMMUTERCARD‐UNRESTRICTED $1.77
TRANSITPLAN3 TRANSITPASSPLAN $3.05
PARKINGPLAN PARKINGPLAN* $3.05
TERMINATEPROGRAM
Ifno,datereferredtoHR:
Date: Phone:
EMPLOYEENAME:
(LocatedonyourtimesheetunderTKID)
PURPOSE(Pleasecheckappropriateboxorboxes,completePartA,andthentheappropriatesection)
ENROLL
PARTA:ENROLLMENT/CHANGEPERSONALINFORMATION(PLEASEPRINT)
Ihavereceivedandreadthe"WhatYouShouldKnowAbouttheWageWorksAccountProgram"document.IunderstandthatIwillbechargedanon‐
refundableadministrativefee,aslistedabove,eachmonthtocoverthecostsoftheprogramandthesefeeswillbedeductedfrommypost‐taxpay.
SUSPEND/RESUMEPARTICIPATION/TERMINATEPARTICIPATION
DEDUCTIONPLANAUTHORIZATION
Step1
:SelecttheplanorplansyouwouldliketoparticipateinbywritingyourinitialsintheEmployeeInitialsBoxFbelow.YoumaychooseonlyoneTransitPlan–Plan1,2,
or3.TheParkingPlanmaybechosenonitsownorinadditiontooneoftheTransitPlans.
Step2
:Writeinyourdesireddeductionamount.ThedeductionamountforTransitPlan1isfixed.FortheotherTransitplans,youmayelectanyperpaycheckdeduction
amountgreaterthan$1.00,howeveryourtotalmonthlydeductionsforallplanscannotexceed$800.Thefirst$265deductedamonthinTransitPlans1,2or3willbe
deductedonapre‐taxbasisandanyamountover$265willbedeductedpost‐tax.TheParkingPlanisaseparateplanfromyourTransitPlanandthefirst$265willbededucted
onapre‐taxbasiswithanyadditionalover$265deductedonpost‐taxbasis.
*ParkingPlanparticipants‐PLEASENOTE:Thisplanislimitedtoauthorizedemployeeparkingfacilitiesorpark&ridefacilitiesasdetailedinthe"WhatYou
ShouldKnowAbouttheWageWorksAccountProgram"document.Inaddition
tosigningupfortheprogramonthisform,youmust,afterreceivinga
welcomingemailfromWageWorks,a)selectatypeofparkingplanpaymentoption,b)placeaparkingorderandc)selectthefrequencyoftheorder.Please
referto"WhatYouShouldKnowAbouttheWageWorksAccountPrograms"document.ontheemployeepayrollwebpageformoreinformation.
IherebyauthorizeNewYorkCityHealth+Hospitalsto(a)deductanddepositmypayrolldeduction(s)asindicatedaboveintomyWageWorksaccount(s),(b)
reverseanycredittomyaccount(s)intheeventthecreditwasmadeinerror,and(c)providemyenrollmentinformation,includinghomeaddress,phone
numberande‐mailaddresstoWageWorks,Inc.forusesexclusivelyrelatedtotheadministrationoftheprogram.Iunderstandthatthisauthorizationwill
remainineffectuntilIsubmitanewrequestforachangeorterminateparticipationoremployment.
IcertifythatIwillbeusingWageWorksproductsforNewYorkCityHealth+Hospitalswork‐relatedcommutingorparkingonlyandthattheaveragemonthly
amountofmytransportationdeductionsshouldnotexceedmyaveragemonthlycostofpublictransportationand/orparkingtoandfromwork.Additionally,
Iunderstandtheavailabilityoffundsfollowingterminationofemploymentandthatfundsmaybeforfeitedifnotusedaccordingly.
EMPLOYEESIGNATURE:
EMPLOYEESIGNATURE:
FORPAYROLLDEPARTMENTUSEONLY
PayrollSchedule: Batch#:
CheckOne:SuspendTerminateDate: DeductionResumptiondate:(PayrollDate)
Name: Signature:
AboveaddressmatchesPSMS?YesNo
PayCycle:W1B1B2Circleone
SUSPENDDEDUCTIONSON(PayrollDate) RESUMEDEDUCTIONSON(PayrollDate)
IunderstandthatmyWageWorksCommuterCardorTransitPassand/orParkingCardwillbemailedtomyhomeaddressonfilewithNewYorkCityHealth+Hospitals.I
understandthattheaboveaddressmustmatchmyhomeaddressonfilewithNewYorkCityHealth+Hospitals.Ifitisdifferent,myenrollment/changewillbedelayeduntil
theaboveaddressagreeswiththehomeaddressonfilewithNewYorkCityHealth+Hospitals.
WORKTELEPHONE:
Submittoyourfacility'sPayrollDepartmentatleast2weeksbeforeyouwanttosuspendyourdeduction(s).Pleasenotethatthiswillonlysuspendyourpayrolldeduction(s),not
anyadministrativefeedeductionifthereisactivityinyourWWaccountduringthesuspensionperiod.ToalsosuspendordersplacedwithWW,youmustdosodirectlywith
WageWorksatwww.wageworks.comor1‐877‐924‐3967.
EMPLOYEESIGNATURE:
revised6/3/2019
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