WilmerHale Commuter Choice

Parking Election and Change Form

Employee First Name:    
Employee Last Name: Last Four Digits of SSN:
Home Mailing Address: City:
State: Zip:
Email: Daytime Telephone:
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 month. 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 (Please enter the monthly election – up to $270 will be pre-tax, any amount over $270 will be post-tax)
  Benefit Month Effective:

I understand and agree to the following:

  1. This monthly election will stay in place at the above rate until you elect to have it changed.
  2. Parking a vehicle in a facility that is near my place of work or 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.) are considered eligible to use your Benefit Strategies VISA debit card to purchase or to submit a manual claim for reimbursement through Benefit Strategies.
  3. Manual claims must be filed within 180 days from the date of service, otherwise the funds may be forfeited.
  4. Any money unclaimed from my reimbursement account(s) at the end of the plan year will be carried over to the next Plan Year on the first day of the plan year.
I agree and understand the above.