Application for Transit Benefit/Bike Share Program

APPLICATION FOR TRANSIT BENEFIT/ BIKE SHARE PROGRAM

PLEASECOMPLETEFORMANDTYPEORPRINTLEGIBLY
(CheckOne)
New Employee Re-certification Replacement Card Increase/Decrease Change ofAddress Personal/Bureau Change
Employment Status: DirectHire Intern Personal Services ContractorOther:
1.Last Name: / 2.FirstName:
3.HomeAddress (Number/Street):
4. City: / 5.State:6.Zip Code: / 6. Zip Code:
7.Bureau: / 8.Room Number: / 9.Phone (Work): / 10. Phone (mobile):
11. Commuting method to and from work:Please provide your daily transportation itineraryto/from work:
Metro RailDaily RoundTrip Fare:$x22* days =$
Metro Rail/Bus(*Reduce number of days for approved telework days.
MARC/VRE/Commuter Bus (CommuterDirect.com)Four(4) days for each approved telework dayper week)
Transit Authority Vanpool
BicycleTransportationSubsidy
Iacceptfullresponsibilityandassume theriskofinjuryordamageto mypersonthatmayarisewhetherdirectly orindirectly
as a result of bicycling/riding
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
ReducedFareProgramforEmployeeswithDisabilitiesandSeniorCitizens
Under these programs,employeeswith disabilities and senior citizens may travel on Metrobus and Metrorail forhalf the regular (rush hour) fare atall times.See fordetails.
12.Are you currently in a carpool with USAID or any other government agencyemployees?
NO YES (Ifyes, primary driver’sname):
13. SmartBenefit Program
Note: In order to receive your Transportation Subsidy Benefit as SmartBenefits, you must purchase and register your SmarTrip card at Your SmarTrip serial number is located on the back side of your card in the lower right-hand corner.
All benefits will be used on the MetroRail/Bus
Split my benefits:
$(MetroRail/bus) and
$ (VRE,MARC, etc.) /
SmarTrip Serial Number:
(attach copy of back of card) /
SmarTrip Serial Number:
(attach copy of back of card)
EMPLOYEECERTIFICATION
Ihereby certifythatIam employed by the United StatesAgency forInternational Developmentand amnotnamed on a Federal- subsidized workplace parking permitwith USAID or other FederalAgency. Iameligible fora public transportation fare benefit, willuse itformydaily commute toand from work and will not transfer ittoanyone else.Mymonthly transit benefitIamreceiving does not exceed mymonthly commuting costs.Iam not receiving Metro benefits from anotherFederalAgency.
EMPLOYEESIGNATURE / DATE:
AMSOFFICER SIGNATURE(I certifythattheaboveindividualis a USAID employeeor othereligibleparticipant) / DATE:
AUTHORIZINGOFFICIALSIGNATURE, M/MS/HMD / DATEAPPROVED:
PRIVACYACTSTATEMENT:This information is solicited under authority ofPublic Law 101-509. Furnishing the information on this formis voluntary,butfailure todo somay resultin disapproval ofyour request fora public transit fare benefit.The purpose ofthis information is tofacilitate timely processing ofyour request,toensure your eligibility, and topreventmisuse ofthe funds involved.This information will be matched with lists atother Federal agencies ofthe Government-assigned parking toensureconsistencywith mode oftransportation checked.

AID 515-1 (11/2017)