ELECTION CHANGE FORM MUST BE COMPLETED AND SUBMITTED ONLINE THROUGH THE WEBSITE --- PLEASE DO NOT PRINT THIS FORM, AS IT WILL NOT BE ACCEPTED IF NOT SUBMITTED ELECTRONICALLY.

Commonwealth of Massachusetts
Qualified Transportation Benefit Plan**

**Also available to benefit eligible UMass employees**

Employee Information
Department Code: (Click here for a Department list.)
Employee ID #: (Check your paystub for your Employee ID#)
Employee First Name:
Employee Last Name:
Home Mailing Address:
City:
State:
Zip:
Email:
Daytime Telephone:
Mass Transit Expense Account
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. Please enter the amount below that you would like to elect per month. If you wish to cease your contribution please enter 0.00.
$ / Month (Max=$130/mo for pre-tax / add post-tax to $130 if greater than $130. Please do not include the $1.50 administration fee in the total of your election amount, as that is deducted separately.)
  Month Effective:
Click here for 2014 Transit Election Change Process Calendar | 2015 Calendar

I understand the following terms of the Mass Transit Benefit:

1. This monthly election will stay in place at the above rate until you elect to have it changed.

2. The cost of any pass, token, fare card, voucher, or other item that entitles the employee to use Mass Transit for purpose of traveling to or from his/her place of work are considered eligible to use your Benefit Strategies VISA debit card to purchase.

3. Mass 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 vehicle's 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
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. Please enter the amount below that you would like to elect per month. If you wish to cease your contribution please enter 0.00.
$ / Month (Max=$250/mo for pre-tax / add post-tax to $250 if greater than $250. Please do not include the $1.50 administration fee in the total of your election amount, as that is deducted separately.)
  Month Effective:
Click here for 2014 Parking Election Change Process Calendar | 2015 Calendar

I understand the following terms of the Parking Benefit:

1. This monthly election will stay in place at the above rate until you elect to have it changed.

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

If you are a current participant in either the Transit or Parking benefit and currently have a FlexExpress© debit card, you will continue to use the same card with the changes made on this form today. If you are canceling your contribution to either benefit temporarily and intend to resume contributions at a later time, please hold on to your FlexExpress© debit card. If you are a new participant to this benefit, you will receive a FlexExpress© debit card in the mail in approximately 7-10 business days from the date when this form is submitted.

I understand that:

1. Any money unclaimed from my reimbursement account(s) at the end of the plan year will be carried over to the next Plan Year.

2. My Social Security benefits may be reduced by this election.

3. I must also agree to the Yearly Certification Form online.

4. 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

1. 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.

2. 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.

3. I understand that the debit card remains active for use until midnight of the last day of the benefit month for which I had a payroll deduction contribution, example: Termination ocurrs in May, and payroll deductions are taken in May paycheck for the June benefit month, I’m allowed to use the account until June 30th.

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

5. 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.

6. If there are any funds remaining in the Transit or Parking account after the benefit is terminated, and the debit card is no longer active, I can submit manual claims for eligible expenses that I incurred within 180 days from the date of service, otherwise the funds will be forfeited. Per IRS regulations, refunds cannot be approved.

I agree Date: mm/dd/yyyy format

 
ELECTION CHANGE FORM MUST BE COMPLETED AND SUBMITTED ONLINE THROUGH THE WEBSITE --- PLEASE DO NOT PRINT THIS FORM, AS IT WILL NOT BE ACCEPTED IF NOT SUBMITTED ELECTRONICALLY.