Commonwealth of Massachusetts
Qualified Transportation Benefit Plan**

**Also available to benefit eligible UMass employees**


  (Click the Department Code link for a Department list.)    
Department Code:   (Check your paystub for your Employee ID#)
Employee Name: (Last, First) Employee ID #:
Home Mailing Address: City:
State: Zip:
Email: Daytime Telephone:
Mass Transit Expense Account
Please check only one option.
I elect to have the following amount of money reduced from my salary before taxes to reimburse me for eligible mass transit expenses I incur during the plan year.
$ / Month (Max=$130/mo for pre-tax / add post-tax to $130 if greater than $130)
  Month Effective:
Click here for Transit Schedule
I am currently enrolled in this benefit and wish to make no changes at this time.
I wish to cease contributions to this account going forward. I understand changes can be made on a month-to month basis and can resume contributions at a later date, if I so choose.

I understand that eligible Mass Transit Expenses include:

  1. The cost of any pass, token, fare card, voucher, or other item that entitles the employee to use mass transit for the purpose of traveling to or from his/her place of work.
  2. Transit may be via:
    • A mass transportation system
    • A private mass transit enterprise conducted by a company or individual that is in the business of transporting people in a “commuter highway vehicle.”  Such a vehicle must have a seating capacity for six or more adults (not including the driver), and at least 80 percent of the vehicles mileage must be from transporting employees to and from their place of work.  Additionally, the vehicle must be used by a minimum of three commuters (not including the driver).  The vehicle may be owned or leased by an employer for use by employees or a third-party provider.  Employees can also own and operate commuter highway vehicles.
Parking Expense Account
Please check only one option.
I elect to have the following amount of money reduced from my salary before taxes to reimburse me for eligible parking expenses I incur during the plan year.
$ / Month (Max=$250/mo for pre-tax / add post-tax to $250 if greater than $250)
  Month Effective:
Click here for Parking Schedule
I am currently enrolled in this benefit and wish to make no changes at this time.
I wish to cease contributions to this account going forward. I understand changes can be made on a month-to month basis and can resume contributions at a later date, if I so choose.

I understand that eligible Parking Expenses include:

  1. Parking a vehicle in a facility that is near my place of work.
  2. Parking at a location from where I commute to work (e.g., the cost of parking in a lot at the train station so that I can commute in on the train.)
FlexExpress© Card

As a participant in the plan, you will be receiving a FlexExpress debit Visa card.  This card can be used to purchase passes on line or at participating merchants.

I understand that:

  • Any money unclaimed from my reimbursement account(s) at the end of the plan year will be carried over to the next Plan Year.
  • My Social Security benefits may be reduced by this election.
  • I must also agree to the Yearly Certification Form On Line.
  • The cost to administer the Transit and Parking program is paid by each employee on a pre-tax basis. The monthly administrative fee is $1.50 for Transit alone, Parking alone, or if you choose to participate in both the Transit and Parking programs you only pay the $1.50 administration fee for both.
I agree


Commonwealth of Massachusetts Qualified Transportation Benefit Plan
Yearly Certification Form

I hereby certify that I have been or will be using this benefit for my regular daily direct commute from home to work and return.* Click for more information. I certify that this card will be used only for qualified transportation fringe benefits, Rev. Rul. 2006-57. I will not give, barter, exchange, convey, assign, or otherwise transfer this benefit to any other person.

I further certify that the monthly benefit that I will be receiving does not exceed my average monthly commuting costs by public transportation, excluding any parking costs, based on the average number of workdays I commute in the average month. I agree that if my commuting costs change and the monthly benefit I receive exceed my average monthly commuting costs for two or more consecutive months, I will notify Benefit Strategies so that my monthly benefit can be adjusted appropriately. I agree to claim my monthly benefit.  I also understand that if I am not receiving the maximum allowable benefit and my commuting costs increase, I can request an increase in my benefit under the State Employee Commuter Benefits Program.  I also understand that I will notify Benefit Strategies immediately when I plan to depart from employment.

I understand I am responsible for purchasing Transit products, and responsible for all requirements of safeguarding these products.

The Employee, under penalties of perjury, certifies that he/she has not and will not claim benefits to which are not allowable under IRS and State Tax law.

REIMBURSEMENT 180 DAYS RULE: Transit and parking claims must be filed within 180 days from the date of service, otherwise the funds may be forfeited.

I agree Date: mm/dd/yyyy format