Check Action DEPARTMENT OF AGRICULTURE Temporary NTE Date

New: \_\_\_ PRE-TAX PARKING APPLICATION \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Change: \_\_\_ (Please type or print legibly in blue or black ink)

# Cancellation: \_\_\_\_

## USDA Agency Name and Code (e.g., Agricultural Marketing Research/02: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

A.  **Applicant Information:**

Last Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ First Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ MI: \_\_\_\_\_\_\_\_

Home Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip Code: \_\_\_\_\_\_\_\_\_\_\_\_

If applicable: Div/Unit
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Rm#/Sub Unit:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip Code: \_\_\_\_\_\_\_\_\_\_\_\_

Work Telephone Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ SSN:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**B. Parking Facility (Please indicate the parking facility you use):**

Metro Lot \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Private Lot
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Public Lot\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Parking Meter \_\_\_\_\_\_\_\_\_\_ Other (explain)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

C.  **Employee Certification:**

**[WARNING]{.underline}**: This certification concerns a matter with the
jurisdiction of an agency of the United States and making a false,
fictitious, or fraudulent certification may render the maker subject to
criminal prosecution under title 18, United States Code, Section 1001
Civility Penalty Action, providing for administrative recoveries of up
to \$10,000 per violation, and/or agency disciplinary actions up to and
including dismissal:

> I certify that I am employed by the Department of Agriculture.
>
> I certify that I am eligible for a pre-tax parking benefit.
>
> I certify that the monthly pre-tax parking I am receiving does not
> exceed my monthly parking cost.
>
> I certify that my usual [monthly]{.underline} parking costs are:
> \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**(NTE Authorized Maximum Amount under
> IRS Code 26)**
>
> Employee's Original Signature:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**D. Transit Subsidy Coordinator:**

> Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Title:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Pay Period Parking Benefit Begins:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Processed By:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Bi-weekly Pre-Tax Benefit Amount:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PRIVACY ACT STATEMENT: This information is solicited under authority of
Public Law 101-509. Furnishing the information on this form is
voluntary, but failure to do so may result in disapproval of your
request for a public transit

fare benefit. The purpose of this information is to facilitate timely
processing of your request, to ensure your eligibility,

and to prevent misuse of the funds involved. AD-1185 dated 06/04/04