Commuter Benefits Plan (Parking) Election/Change Form

Commuter Benefit Plan (Parking) Election/Change Form

The Parking Reimbursement Account allows you to set aside money from your paycheck on a pre-tax basis to pay for work-related parking expenses. That means you do not pay federal, and in most cases, state income tax, or FICA taxes on those dollars. Eligible expenses include those you incur at a parking lot or garage, or for metered street parking.

You can defer the cost of your monthly off campus parking expense (up to $300 per month) into your parking account. This monthly limit is set by the IRS and is subject to change. You may start, stop, or change your election at any time.

You may only be reimbursed for expenses incurred after you begin participating in the Plan. Expenses will be reimbursed after sums have been deferred from your pay to your account. Amounts remaining in your account following your termination of employment with the University will be forfeited.

Name

First

Last

UNID

Phone

University Building Address

Are you opting into the commuter benefit plan or canceling your existing election?

I elect an amount to be deferred each pay period to a Parking Reimbursement Account on a pre-tax basis. I direct that this election be automatically renewed each pay period and that this amount continue to be deducted each pay period until I file a new form requesting a change or cancellation of deductions. The Internal Revenue Code limits the amount you may pay pre-tax for parking to $300 per month.

I understand

Per Paycheck Election: $_____? (Minimum of $10 per pay period / Maximum of $127.50 per pay period)

Desired Election Effective Date (Elections cannot be retroactive and must be submitted before the end of the pay period):

7th Paycheck

22nd Paycheck

What month should this start?

Please check off each box to indicate you understand and authorize the following:

I elect the benefits indicated above and authorize the appropriate payroll deferrals. I understand pretax deductions reduce my compensation for tax purposes which also reduces the amount of compensation reported for Social Security calculations.

To be eligible, expenses must not be paid, reimbursed, or reimbursable from any other source. I am responsible to request reimbursement and must provide documentation of the expense, including the parking facility name, date of parking and the dollar amount paid.

I understand I may change or cancel this election on a prospective basis by filing a new form. Amounts deducted pursuant to an existing election cannot be refunded.

Unreimbursed amounts left in my Commuter Benefit Plan Account are forfeited following termination of my employment. I have 30 days following termination of employment to request reimbursement of eligible expenses.

If I also have amounts deducted pre-tax from my pay for a University parking pass, I acknowledge that I am responsible to ensure pre-tax payroll deduction and my election for this plan combined do not exceed the $300 monthly maximum.

I have read and understand the above information. I certify the information I have provided on all parts of this form is true and correct. I hereby authorize the payroll deductions of amounts elected.

Electronic Signature

Date

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