+----------------+-----+---+------+-----+----+---+--------+---------+
| # PUBLIC       |     |   |      |     |    |   |        |         |
|  TRANSPORTATIO |     |   |      |     |    |   |        |         |
| N BENEFIT EXPE |     |   |      |     |    |   |        |         |
| NSE WORK SHEET |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **NOTE:** USDA |     |   |      |     |    |   |        |         |
| Form AD-1147,  |     |   |      |     |    |   |        |         |
| Public         |     |   |      |     |    |   |        |         |
| Transportation |     |   |      |     |    |   |        |         |
| Benefit        |     |   |      |     |    |   |        |         |
| Program        |     |   |      |     |    |   |        |         |
| Application,   |     |   |      |     |    |   |        |         |
| requires USDA  |     |   |      |     |    |   |        |         |
| participants   |     |   |      |     |    |   |        |         |
| to calculate   |     |   |      |     |    |   |        |         |
| their usual    |     |   |      |     |    |   |        |         |
| monthly mass   |     |   |      |     |    |   |        |         |
| transit        |     |   |      |     |    |   |        |         |
| commuting cost |     |   |      |     |    |   |        |         |
| to the nearest |     |   |      |     |    |   |        |         |
| dollar for     |     |   |      |     |    |   |        |         |
| their [daily   |     |   |      |     |    |   |        |         |
| commute to and |     |   |      |     |    |   |        |         |
| fro            |     |   |      |     |    |   |        |         |
| m]{.underline} |     |   |      |     |    |   |        |         |
| work. This     |     |   |      |     |    |   |        |         |
| work sheet     |     |   |      |     |    |   |        |         |
| must be        |     |   |      |     |    |   |        |         |
| completed to   |     |   |      |     |    |   |        |         |
| receive        |     |   |      |     |    |   |        |         |
| transit        |     |   |      |     |    |   |        |         |
| subsidy        |     |   |      |     |    |   |        |         |
| benefits.      |     |   |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
| **I            |     |   |      |     |    |   |        |         |
| NSTRUCTIONS:** |     |   |      |     |    |   |        |         |
| Calculate your |     |   |      |     |    |   |        |         |
| total monthly  |     |   |      |     |    |   |        |         |
| mass transit   |     |   |      |     |    |   |        |         |
| expenses by    |     |   |      |     |    |   |        |         |
| the way you    |     |   |      |     |    |   |        |         |
| pay for your   |     |   |      |     |    |   |        |         |
| **[roundtrip   |     |   |      |     |    |   |        |         |
| daily commute  |     |   |      |     |    |   |        |         |
| to and from    |     |   |      |     |    |   |        |         |
| work]{         |     |   |      |     |    |   |        |         |
| .underline}**. |     |   |      |     |    |   |        |         |
| Using the work |     |   |      |     |    |   |        |         |
| sheet below,   |     |   |      |     |    |   |        |         |
| select your    |     |   |      |     |    |   |        |         |
| mode of mass   |     |   |      |     |    |   |        |         |
| transportation |     |   |      |     |    |   |        |         |
| and identify   |     |   |      |     |    |   |        |         |
| the            |     |   |      |     |    |   |        |         |
| **roundtrip    |     |   |      |     |    |   |        |         |
| cost based on  |     |   |      |     |    |   |        |         |
| how you pay    |     |   |      |     |    |   |        |         |
| (i.e. daily,   |     |   |      |     |    |   |        |         |
| weekly,        |     |   |      |     |    |   |        |         |
| monthly) for   |     |   |      |     |    |   |        |         |
| your fare      |     |   |      |     |    |   |        |         |
| media and      |     |   |      |     |    |   |        |         |
| convert all    |     |   |      |     |    |   |        |         |
| costs to a     |     |   |      |     |    |   |        |         |
| total monthly  |     |   |      |     |    |   |        |         |
| amount**.      |     |   |      |     |    |   |        |         |
| **REMINDER:**  |     |   |      |     |    |   |        |         |
| It is possible |     |   |      |     |    |   |        |         |
| that an        |     |   |      |     |    |   |        |         |
| employee may   |     |   |      |     |    |   |        |         |
| have a         |     |   |      |     |    |   |        |         |
| combination of |     |   |      |     |    |   |        |         |
| daily, weekly  |     |   |      |     |    |   |        |         |
| or monthly     |     |   |      |     |    |   |        |         |
| expenses in    |     |   |      |     |    |   |        |         |
| computing      |     |   |      |     |    |   |        |         |
| his/her total  |     |   |      |     |    |   |        |         |
| monthly        |     |   |      |     |    |   |        |         |
| commuting      |     |   |      |     |    |   |        |         |
| costs.         |     |   |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
| **REMEMBER:**  |     |   |      |     |    |   |        |         |
| Parking fees   |     |   |      |     |    |   |        |         |
| are not        |     |   |      |     |    |   |        |         |
| allowed and    |     |   |      |     |    |   |        |         |
| cannot be      |     |   |      |     |    |   |        |         |
| included when  |     |   |      |     |    |   |        |         |
| computing      |     |   |      |     |    |   |        |         |
| monthly        |     |   |      |     |    |   |        |         |
| transit costs. |     |   |      |     |    |   |        |         |
| If you are a   |     |   |      |     |    |   |        |         |
| person with a  |     |   |      |     |    |   |        |         |
| disability or  |     |   |      |     |    |   |        |         |
| a senior       |     |   |      |     |    |   |        |         |
| citizen        |     |   |      |     |    |   |        |         |
| receiving      |     |   |      |     |    |   |        |         |
| reduced rates, |     |   |      |     |    |   |        |         |
| you must       |     |   |      |     |    |   |        |         |
| calculate the  |     |   |      |     |    |   |        |         |
| reduced fare   |     |   |      |     |    |   |        |         |
| rate you pay.  |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **MODE OF      | ### |   | **   |     | *  |   | **     | **      |
| TR             | ##  |   | NAME |     | *D |   | WEEKLY | MONTHLY |
| ANSPORTATION** | DEP |   | OF   |     | AI |   | PASS** | PASS**  |
|                | ART |   | C    |     | LY |   |        |         |
|                | URE |   | OMPA |     | E  |   | **EXP  | **EX    |
|                |     |   | NY** |     | XP |   | ENSE** | PENSE** |
|                | ### |   |      |     | EN |   |        |         |
|                | ### |   |      |     | SE |   |        |         |
|                |  LO |   |      |     | ** |   |        |         |
|                | CAT |   |      |     |    |   |        |         |
|                | ION |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Bus (circle    |     |   |      |     | \$ |   | \$     | \$      |
| applicable)    |     |   |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
| Local -        |     |   |      |     |    |   |        |         |
| Commuter -     |     |   |      |     |    |   |        |         |
| County         |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Rail (circle   |     |   |      |     | \$ |   | \$     | \$      |
| applicable)    |     |   |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
| Light Rail -   |     |   |      |     |    |   |        |         |
| Subway         |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Commuter Train |     |   |      |     | \$ |   | \$     | \$      |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Vanpool        |     |   |      |     | \$ |   | \$     | \$      |
| (authorized)   |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Ferry          |     |   |      |     | \$ |   | \$     | \$      |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Other          |     |   |      |     | \$ |   | \$     | \$      |
| (Specify)      |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| ##             |     |   |      |     | \$ |   | \$     | \$      |
| ##  TOTAL COST |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| ### CONVER     |     |   |      |     |    |   |        |         |
| TING DAILY AND |     |   |      |     |    |   |        |         |
|  WEEKLY COST T |     |   |      |     |    |   |        |         |
| O MONTHLY COST |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| ### 40 HOUR    |     |   |      |     |    |   |        |         |
| WORKWEEK SCHED |     |   |      |     |    |   |        |         |
| ULE CONVERSION |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **8 HOUR WORK  |     | * |      |     |    | * |        |         |
| DAY            |     | * |      |     |    | * |        |         |
| CONVERSION**   |     | 9 |      |     |    | 1 |        |         |
|                |     | H |      |     |    | 0 |        |         |
|                |     | O |      |     |    | H |        |         |
|                |     | U |      |     |    | O |        |         |
|                |     | R |      |     |    | U |        |         |
|                |     | W |      |     |    | R |        |         |
|                |     | O |      |     |    | W |        |         |
|                |     | R |      |     |    | O |        |         |
|                |     | K |      |     |    | R |        |         |
|                |     | D |      |     |    | K |        |         |
|                |     | A |      |     |    | D |        |         |
|                |     | Y |      |     |    | A |        |         |
|                |     | C |      |     |    | Y |        |         |
|                |     | O |      |     |    | C |        |         |
|                |     | N |      |     |    | O |        |         |
|                |     | V |      |     |    | N |        |         |
|                |     | E |      |     |    | V |        |         |
|                |     | R |      |     |    | E |        |         |
|                |     | S |      |     |    | R |        |         |
|                |     | I |      |     |    | S |        |         |
|                |     | O |      |     |    | I |        |         |
|                |     | N |      |     |    | O |        |         |
|                |     | * |      |     |    | N |        |         |
|                |     | * |      |     |    | * |        |         |
|                |     |   |      |     |    | * |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Daily Cost No. |     | D |      |     |    | D |        |         |
| Days Total     |     | a |      |     |    | a |        |         |
| Cost           |     | i |      |     |    | i |        |         |
|                |     | l |      |     |    | l |        |         |
| Worked Per     |     | y |      |     |    | y |        |         |
| Month          |     | C |      |     |    | C |        |         |
|                |     | o |      |     |    | o |        |         |
| \$ x's 21 \$   |     | s |      |     |    | s |        |         |
|                |     | t |      |     |    | t |        |         |
|                |     | N |      |     |    | N |        |         |
|                |     | o |      |     |    | o |        |         |
|                |     | . |      |     |    | . |        |         |
|                |     | D |      |     |    | D |        |         |
|                |     | a |      |     |    | a |        |         |
|                |     | y |      |     |    | y |        |         |
|                |     | s |      |     |    | s |        |         |
|                |     | T |      |     |    | T |        |         |
|                |     | o |      |     |    | o |        |         |
|                |     | t |      |     |    | t |        |         |
|                |     | a |      |     |    | a |        |         |
|                |     | l |      |     |    | l |        |         |
|                |     | C |      |     |    | C |        |         |
|                |     | o |      |     |    | o |        |         |
|                |     | s |      |     |    | s |        |         |
|                |     | t |      |     |    | t |        |         |
|                |     |   |      |     |    |   |        |         |
|                |     | W |      |     |    | W |        |         |
|                |     | o |      |     |    | o |        |         |
|                |     | r |      |     |    | r |        |         |
|                |     | k |      |     |    | k |        |         |
|                |     | e |      |     |    | e |        |         |
|                |     | d |      |     |    | d |        |         |
|                |     | P |      |     |    | P |        |         |
|                |     | e |      |     |    | e |        |         |
|                |     | r |      |     |    | r |        |         |
|                |     | M |      |     |    | M |        |         |
|                |     | o |      |     |    | o |        |         |
|                |     | n |      |     |    | n |        |         |
|                |     | t |      |     |    | t |        |         |
|                |     | h |      |     |    | h |        |         |
|                |     |   |      |     |    |   |        |         |
|                |     | \ |      |     |    | \ |        |         |
|                |     | $ |      |     |    | $ |        |         |
|                |     | x |      |     |    | x |        |         |
|                |     | ' |      |     |    | ' |        |         |
|                |     | s |      |     |    | s |        |         |
|                |     | 1 |      |     |    | 1 |        |         |
|                |     | 9 |      |     |    | 7 |        |         |
|                |     | \ |      |     |    | \ |        |         |
|                |     | $ |      |     |    | $ |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **LESS THAN    |     |   |      |     |    |   |        |         |
| 40-HOUR        |     |   |      |     |    |   |        |         |
| WORKWEEK       |     |   |      |     |    |   |        |         |
| SCHEDULE       |     |   |      |     |    |   |        |         |
| CONVERSION**   |     |   |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
| **Complete     |     |   |      |     |    |   |        |         |
| this section   |     |   |      |     |    |   |        |         |
| if your work   |     |   |      |     |    |   |        |         |
| schedule has   |     |   |      |     |    |   |        |         |
| you out of the |     |   |      |     |    |   |        |         |
| official duty  |     |   |      |     |    |   |        |         |
| station        |     |   |      |     |    |   |        |         |
| location for   |     |   |      |     |    |   |        |         |
| less than 40   |     |   |      |     |    |   |        |         |
| hours per      |     |   |      |     |    |   |        |         |
| week.**        |     |   |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
| **(i.e.        |     |   |      |     |    |   |        |         |
| telework,      |     |   |      |     |    |   |        |         |
| part-time,     |     |   |      |     |    |   |        |         |
| regularly      |     |   |      |     |    |   |        |         |
| scheduled      |     |   |      |     |    |   |        |         |
| travel,        |     |   |      |     |    |   |        |         |
| etc.)**        |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Daily Mass     |     | N |      |     |    | T |        |         |
| Transit Cost   |     | u |      |     |    | o |        |         |
|                |     | m |      |     |    | t |        |         |
| \$             |     | b |      |     |    | a |        |         |
|                |     | e |      |     |    | l |        |         |
|                |     | r |      |     |    | D |        |         |
|                |     | o |      |     |    | a |        |         |
|                |     | f |      |     |    | i |        |         |
|                |     | D |      |     |    | l |        |         |
|                |     | a |      |     |    | y |        |         |
|                |     | y |      |     |    | C |        |         |
|                |     | s |      |     |    | o |        |         |
|                |     | W |      |     |    | s |        |         |
|                |     | o |      |     |    | t |        |         |
|                |     | r |      |     |    | P |        |         |
|                |     | k |      |     |    | e |        |         |
|                |     | e |      |     |    | r |        |         |
|                |     | d |      |     |    | M |        |         |
|                |     | P |      |     |    | o |        |         |
|                |     | e |      |     |    | n |        |         |
|                |     | r |      |     |    | t |        |         |
|                |     | M |      |     |    | h |        |         |
|                |     | o |      |     |    |   |        |         |
|                |     | n |      |     |    | \ |        |         |
|                |     | t |      |     |    | $ |        |         |
|                |     | h |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
|                |     | x |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **WEEKLY PASS  |     |   |      |     |    |   |        |         |
| CONVERSION (If |     |   |      |     |    |   |        |         |
| applicable)**  |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| Weekly Mass    |     | N |      |     |    | T |        |         |
| Transit Cost   |     | u |      |     |    | o |        |         |
|                |     | m |      |     |    | t |        |         |
| \$             |     | b |      |     |    | a |        |         |
|                |     | e |      |     |    | l |        |         |
|                |     | r |      |     |    | W |        |         |
|                |     | o |      |     |    | e |        |         |
|                |     | f |      |     |    | e |        |         |
|                |     | W |      |     |    | k |        |         |
|                |     | e |      |     |    | l |        |         |
|                |     | e |      |     |    | y |        |         |
|                |     | k |      |     |    | C |        |         |
|                |     | s |      |     |    | o |        |         |
|                |     | P |      |     |    | s |        |         |
|                |     | e |      |     |    | t |        |         |
|                |     | r |      |     |    | P |        |         |
|                |     | M |      |     |    | e |        |         |
|                |     | o |      |     |    | r |        |         |
|                |     | n |      |     |    | M |        |         |
|                |     | t |      |     |    | o |        |         |
|                |     | h |      |     |    | n |        |         |
|                |     |   |      |     |    | t |        |         |
|                |     | x |      |     |    | h |        |         |
|                |     | 4 |      |     |    |   |        |         |
|                |     |   |      |     |    | \ |        |         |
|                |     |   |      |     |    | $ |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **NOTE:** If   |     |   |      |     |    |   |        |         |
| the scheduled  |     |   |      |     |    |   |        |         |
| number of      |     |   |      |     |    |   |        |         |
| hours you work |     |   |      |     |    |   |        |         |
| per month      |     |   |      |     |    |   |        |         |
| changes, see   |     |   |      |     |    |   |        |         |
| your Commuter  |     |   |      |     |    |   |        |         |
| Benefit        |     |   |      |     |    |   |        |         |
| Coordinator    |     |   |      |     |    |   |        |         |
| for options.   |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **TOTAL        |     |   |      |     |    |   |        |         |
| MONTHLY        |     |   |      |     |    |   |        |         |
| COMMUTING      |     |   |      |     |    |   |        |         |
| COSTS**        |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| TOTAL DAILY    |     |   |      | \$  |    |   |        |         |
| COST PER MONTH |     |   |      |     |    |   |        |         |
| (if            |     |   |      |     |    |   |        |         |
| applicable)    |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| TOTAL WEEKLY   |     |   |      | \$  |    |   |        |         |
| COST PER MONTH |     |   |      |     |    |   |        |         |
| (if            |     |   |      |     |    |   |        |         |
| applicable)    |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| TOTAL MONTHLY  |     |   |      | \$  |    |   |        |         |
| COST PER MONTH |     |   |      |     |    |   |        |         |
| (if            |     |   |      |     |    |   |        |         |
| applicable)    |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **GRAND TOTAL  |     |   |      | \$  |    |   |        |         |
| OF MONTHLY     |     |   |      |     |    |   |        |         |
| COMMUTING      |     |   |      |     |    |   |        |         |
| COSTS (rounded |     |   |      |     |    |   |        |         |
| to the nearest |     |   |      |     |    |   |        |         |
| dollar).       |     |   |      |     |    |   |        |         |
| Transfer to    |     |   |      |     |    |   |        |         |
| front page     |     |   |      |     |    |   |        |         |
| under Employee |     |   |      |     |    |   |        |         |
| Ce             |     |   |      |     |    |   |        |         |
| rtification.** |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **EMPLOYEE     |     |   |      |     |    |   |        |         |
| C              |     |   |      |     |    |   |        |         |
| ERTIFICATION** |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **NAME OF      |     | * |      |     |    | * |        |         |
| EMPLOYEEE      |     | * |      |     |    | * |        |         |
| (Please print  |     | S |      |     |    | D |        |         |
| name)**        |     | I |      |     |    | A |        |         |
|                |     | G |      |     |    | T |        |         |
|                |     | N |      |     |    | E |        |         |
|                |     | A |      |     |    | * |        |         |
|                |     | T |      |     |    | * |        |         |
|                |     | U |      |     |    |   |        |         |
|                |     | R |      |     |    |   |        |         |
|                |     | E |      |     |    |   |        |         |
|                |     | O |      |     |    |   |        |         |
|                |     | F |      |     |    |   |        |         |
|                |     | E |      |     |    |   |        |         |
|                |     | M |      |     |    |   |        |         |
|                |     | P |      |     |    |   |        |         |
|                |     | L |      |     |    |   |        |         |
|                |     | O |      |     |    |   |        |         |
|                |     | Y |      |     |    |   |        |         |
|                |     | E |      |     |    |   |        |         |
|                |     | E |      |     |    |   |        |         |
|                |     | * |      |     |    |   |        |         |
|                |     | * |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **SUPERVISOR   |     |   |      |     |    |   |        |         |
| CERTIFICATION  |     |   |      |     |    |   |        |         |
| OF WORK        |     |   |      |     |    |   |        |         |
| SCHEDULE**     |     |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| **NAME OF      |     | * |      |     |    | * |        |         |
| SUPERVISOR     |     | * |      |     |    | * |        |         |
| (Please print  |     | S |      |     |    | D |        |         |
| name)**        |     | I |      |     |    | A |        |         |
|                |     | G |      |     |    | T |        |         |
|                |     | N |      |     |    | E |        |         |
|                |     | A |      |     |    | * |        |         |
|                |     | T |      |     |    | * |        |         |
|                |     | U |      |     |    |   |        |         |
|                |     | R |      |     |    |   |        |         |
|                |     | E |      |     |    |   |        |         |
|                |     | O |      |     |    |   |        |         |
|                |     | F |      |     |    |   |        |         |
|                |     | S |      |     |    |   |        |         |
|                |     | U |      |     |    |   |        |         |
|                |     | P |      |     |    |   |        |         |
|                |     | E |      |     |    |   |        |         |
|                |     | R |      |     |    |   |        |         |
|                |     | V |      |     |    |   |        |         |
|                |     | I |      |     |    |   |        |         |
|                |     | S |      |     |    |   |        |         |
|                |     | O |      |     |    |   |        |         |
|                |     | R |      |     |    |   |        |         |
|                |     | * |      |     |    |   |        |         |
|                |     | * |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+

**BACK of AD - 1147 dated December 30, 2005 (Revised -- other versions
of form obsolete)**

#