Metrochek/Smart Benefits Enrollment Form Name:____________________________________________ U.I.D. No. (not S.S.N.) __________________________ Campus Dept. & Address: __________________________________________________________________________ Contact Telephone No:____________________ ____ E-mail Address:_____________________________________ Home Address:____________________________________________________________________________________ Affiliation: (check one) Faculty_______ Staff_______ Grad Asst_______ Teaching Asst_______ Which public transit service(s) do you use? Metrorail_____ Metrobus_____ MARC_____ Ride-On_____ The Bus_____ Other_____ If you ride MARC Rail, or any other transit provider that has not yet integrated to the SmarTrip card, your monthly benefit will be issued to you in the form of Smart Benefit Vouchers. These vouchers can be used to purchase fare from these providers. If you utilize a transit provider that accepts the SmartTrip card, then your benefit will be assigned to your (registered) SmartTrip card. If you already have a SmarTrip card, please provide the serial number below. It will be a set of 9-10 digits (all numbers, no letters) located on the back of the card. In order for DOTS to assign benefits, the SmarTrip card must be registered, in the employee’s name, with WMATA. Your SmarTrip Card Serial Number________________________________________ _______Check here if you need a SmarTrip card Card No. Assigned______________________ IMPORTANT INFORMATION Payroll deductions are taken only 20 pay periods per year (pay periods 5 through 24). There are no deductions taken from your pay for pay periods 25, 26, and 1-4 (summer months), and therefore no benefit is provided for non-deducted pay periods. If you are in need of a transit benefit year-round, then you should increase your deduction during the 20 pay periods to allow you to accumulate funds during the year for use during the summer months when there is no deduction or benefit. Deductions are taken from your pay bi-weekly, but the Metrochek/SmarTrip benefit is issued monthly. There is lag time in when you receive your benefit. Deductions taken in one month are issued as your transit benefit the following month. Metrochek and SmarTrip benefits are for the exclusive use by the employee. If you fail to claim your benefit for three consecutive months, you may be cancelled out of the program. Your bi-weekly (per pay period) deduction options are: $30 $36 $45 $51 $60 $66 $78 $85 $100 $115 $125 $138 Please circle the amount you authorize to have deducted from your pay. Authorization I regularly use public transportation for my commute to work and wish to enroll in the Metrochek program. ____________________________________________________ ____________________________ Signature Date To enroll, send or bring this form, along with a Metrochek/Smart Benefits Payroll Deduction Authorization to The Department of Transportation Services, Regents Drive Garage.
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