www.wageworks.com
Special Handling Form
TOLL-FREE FAX: (877) 353-9236
Or, mail to:
WageW orks Processing Center
Attn.: Special Handling, PO Box 60010, Phoenix, AZ 85082
ACCOUNT HOLDER INFORMATION
Last Name First Name
ID Code (last 4 digits)
*
Employer / Program Sponsor's Name
Zip Code Birth Month/Day (MM/DD) Email Address (complete only if new)
CERTIFICATION AND AUTHORIZATION
My signature certifies that the information on this page is correct and complete.
Signature of Account Holder X
Date
ABOUT YOUR PASS
Name of Service Operator
$
Type of Pass Benefit Month (MM/YY) Amount
OPTION 1: REQUEST FOR REIMBURSEMENT
I want to be reimbursed. I had to buy a replacement pass because (check one):
I
did not receive my pass by the first day of the benefit month.
My late pass is enclosed.
My late pass is NOT enclosed. (I am obligated to return the pass to WageWorks if I ever receive it.)
I received a different pass than the one I ordered. (I am enclosing the pass I received.)
I received a defective pass that has never worked. (I must enclose the pass to receive reimbursement. If my pass worked at least
once, then I cannot receive reimbursement from WageWorks but should return the defective pass to my service provider.)
OPTION 2: REQUEST FOR CREDIT
The following situation may result in a credit, rather than a reimbursement. Any credit issued will be applied to reduce your next
commuter pre-tax payroll deduction automatically.
I
would like a credit for a pass I cannot use. (I am enclosing the pass, which will be returned to the service operator. I understand
that I will receive credit only if and when the service operator provides a credit to WageWorks.)
OP
TION 3: RETURN PASS
Complete this section only if you have already submitted a request for reimbursement on the pass you are returning.
I
received my pass after I purchased a replacement pass and requested reimbursement (I am enclosing the pass I received late.)
*
Your ID Code is the last 4 digits of your Social Security Number, your Employee Number or other reference number assigned by your program sponsor.
Please check the enrollment instructions provided by your program
sponsor for more information about your ID Code.
3725 (10/2014)
