Metrocheck.Smart Benefits Enrollment Form

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.