Commonwealth Commuter Choice Employee Enrollment Form
Northern Virginia Community College

(Employee’s Name and Social Security Number)

I hereby enroll for a monthly transportation fringe benefit from the Commonwealth of Virginia under the Commonwealth Commuter Choice program. I hereby request a monthly amount of transportation fringe benefit, paid for by my employer, the Commonwealth of Virginia, valued at $__________ per month in Metrochek, Commuter Bonus Bucks, Commuter Checks vouchers, or other transit or vanpool vouchers, passes, tokens, tickets, fare cards or other authorized transportation benefit media.

I hereby certify that I will be using this benefit exclusively for my regular daily direct commute from home to work and return. I will not give, barter, exchange, convey or otherwise transfer this benefit to any other person.

I further certify that the monthly benefit that I will be receiving does not exceed my average monthly commuting costs by public transportation or eligible vanpool, excluding any parking costs, based on the average number of workdays I commute in the average month. I agree that if my commuting costs change and the monthly benefit I receive exceeds my average monthly commuting costs for two or more consecutive months, I will notify my agency so that my monthly benefit can be adjusted appropriately. I also understand that if I am not receiving the maximum allowable benefit and my commuting costs increase, I can request an increase in my benefit under the Commonwealth Commuter Choice program.

I further certify that I am not presently receiving any benefit under the Commonwealth Commuter Choice program or any other similar transportation fringe benefit from any other agency, department, or division of the Commonwealth of Virginia, unless that is disclosed at the bottom of this form. I will notify this agency immediately in the event that I receive any such benefit from another state agency, department, or division during my employment with this agency.

I understand and agree that false information in this application may result in disciplinary action taken by my agency or the Commonwealth of Virginia, up to and including dismissal from my employment, and may subject me to criminal prosecution under state or federal law.

Signed: ________________________________ Date: ____________________

(Signature of Employee)

Other state agencies from which I am receiving transportation fringe benefits, excluding parking benefits, and the amount: ________________________________________________________

Commonwealth Commuter Choice Employee Yearly Certification

For the Year ____________

Northern Virginia Community College

I hereby acknowledge receipt of a monthly transportation fringe benefit from the Commonwealth Commuter Choice program, paid for by my employer, the Commonwealth of Virginia, valued at $__________ per month, provided to me in the form of Metrochek, Commuter Bonus Bucks, or Commuter Checks vouchers, other transit or vanpool vouchers, passes, tokens, tickets, fare cards or other authorized transportation benefit media, for the period from ______________________________ to _______________________________ .

I certify that during this period I used the benefits exclusively for my regular daily direct commute from home to work and return by public transportation or eligible vanpool, and that I did not give, barter, exchange, convey, or otherwise transfer any of these benefits to any other person.

I further certify that the total of the monthly benefits that I received did not exceed my total commuting costs, excluding any parking costs, for the period I received them.

I further certify that during this period I did not receive any benefit under the Commonwealth Commuter Choice program or any other similar transportation fringe benefit from any other agency, department, or division of the Commonwealth of Virginia, unless it was disclosed, in writing, to this agency.

I understand and agree that false certification may result in disciplinary action taken by my agency or the Commonwealth of Virginia, up to and including dismissal from employment, and may subject me to criminal prosecution under state or federal law.

Signed: ______________________________________Date: ____________________

(Signature of Employee)

Name of Employee: _____________________________________________________

(Please Print)