"Commuter Benefits (Parking/Transit) Claim Form - Asi Flex"

ADVERTISEMENT
ADVERTISEMENT

Download "Commuter Benefits (Parking/Transit) Claim Form - Asi Flex"

Download PDF

Fill PDF online

Rate (4.6 / 5) 11 votes
Commuter Benefits (Parking/Transit) Claim Form
Your Name (Last, First, MI)
Social Security No. or EID or PIN
Your Employer Name
Address
City
State
Zip Code
Parking Account Claims
Attach documentation or a receipt to substantiate the expenses you are claiming. The receipt or documentation must include the parking facility name, the date
range of parking, and the dollar amount paid. If receipts are not provided in the ordinary course of business please explain below.
Date of Parking
Name of Parking Facility
If documentation is not available, explain why it is not
Amount
provided by the parking facility.
Requested
Start Date
End Date
(For example, metered street parking does not provide a receipt.)
$
$
$
Total
$
0
Transit/Van Pooling Account Claims
Attach documentation or a receipt to substantiate the expenses you are claiming. The receipt or documentation must include the transit authority name, the date
of transportation, and the dollar amount paid. If receipts are not provided in the ordinary course of business please explain below.
Date of Transportation
Name of Transit Authority
If documentation is not available, explain why it is not
Amount
provided by the transit authority.
Requested
Start Date
End Date
(For example, cash paid for bus; bus does not provide a receipt.)
$
$
$
Total
$
0
I certify that all expenses for which reimbursement or payment is claimed by submission of this form were incurred by me during a period while I was covered under
my employer's Commuter Benefit Plan and that the expenses have not been reimbursed and reimbursement will not be sought from any other source. I certify that
the expenses were incurred by me for the purpose of commuting to and from my place of employment. I understand that I am fully responsible for the accuracy of all
information relating to this claim, and that unless an expense for which reimbursement is claimed is a proper expense under the Plan, I may be liable for payment of
all related taxes including federal, state, or local income tax on amounts paid from the Plan which relate to such expense. A claim will only be processed with a
completed and signed claim form and correct documentation. I understand IRS regulations establish the amount that can be reimbursed each month and that these
amounts are subject to change and without notice.
Employee Signature ___________________________________________________________
Date____________________________________________
FAX TO: 1-877-879-9038
MAIL TO: ASI
PAGE 1 OF __________
PO BOX 6044
NO COVER PAGE REQUIRED
COLUMBIA, MO 65205-6044
REV. 01022014
Commuter Benefits (Parking/Transit) Claim Form
Your Name (Last, First, MI)
Social Security No. or EID or PIN
Your Employer Name
Address
City
State
Zip Code
Parking Account Claims
Attach documentation or a receipt to substantiate the expenses you are claiming. The receipt or documentation must include the parking facility name, the date
range of parking, and the dollar amount paid. If receipts are not provided in the ordinary course of business please explain below.
Date of Parking
Name of Parking Facility
If documentation is not available, explain why it is not
Amount
provided by the parking facility.
Requested
Start Date
End Date
(For example, metered street parking does not provide a receipt.)
$
$
$
Total
$
0
Transit/Van Pooling Account Claims
Attach documentation or a receipt to substantiate the expenses you are claiming. The receipt or documentation must include the transit authority name, the date
of transportation, and the dollar amount paid. If receipts are not provided in the ordinary course of business please explain below.
Date of Transportation
Name of Transit Authority
If documentation is not available, explain why it is not
Amount
provided by the transit authority.
Requested
Start Date
End Date
(For example, cash paid for bus; bus does not provide a receipt.)
$
$
$
Total
$
0
I certify that all expenses for which reimbursement or payment is claimed by submission of this form were incurred by me during a period while I was covered under
my employer's Commuter Benefit Plan and that the expenses have not been reimbursed and reimbursement will not be sought from any other source. I certify that
the expenses were incurred by me for the purpose of commuting to and from my place of employment. I understand that I am fully responsible for the accuracy of all
information relating to this claim, and that unless an expense for which reimbursement is claimed is a proper expense under the Plan, I may be liable for payment of
all related taxes including federal, state, or local income tax on amounts paid from the Plan which relate to such expense. A claim will only be processed with a
completed and signed claim form and correct documentation. I understand IRS regulations establish the amount that can be reimbursed each month and that these
amounts are subject to change and without notice.
Employee Signature ___________________________________________________________
Date____________________________________________
FAX TO: 1-877-879-9038
MAIL TO: ASI
PAGE 1 OF __________
PO BOX 6044
NO COVER PAGE REQUIRED
COLUMBIA, MO 65205-6044
REV. 01022014