+-----------------------+-----------+------------+---------------------+
| # DEPA                |           |            |                     |
| RTMENT OF AGRICULTURE |           |            |                     |
|                       |           |            |                     |
| # PUBLIC              |           |            |                     |
| TRANSPORTATION BENEFI |           |            |                     |
| T PROGRAM APPLICATION |           |            |                     |
|                       |           |            |                     |
| (Please type or print |           |            |                     |
| legibly in blue or    |           |            |                     |
| black ink)            |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| ####### ACTIO         |           |            |                     |
| N REQUESTED (CHECK ON |           |            |                     |
| E):  New Change Cance |           |            |                     |
| llation Recertificati |           |            |                     |
| on Temporary NTE DATE |           |            |                     |
| : [     ]{.underline} |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| NOTE: Items 1 through |           |            |                     |
| 12, and the reverse   |           |            |                     |
| side of this form     |           |            |                     |
| must be completed in  |           |            |                     |
| full before           |           |            |                     |
| submitting to your    |           |            |                     |
| designated Commuter   |           |            |                     |
| Benefit Coordinator.  |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| ##                    |           |            |                     |
| APPLICANT INFORMATION |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| 1.  NAME OF APPLICANT | 2.  WORK  |            | 3.  HOME ADDRESS    |
|     (Last, First,     |           |            |     (Street, City,  |
|     Middle Initial)   |   ADDRESS |            |     State, Zip      |
|                       |           |            |     Code)           |
| >                     |  (Street, |            |                     |
|                       |     City, |            | [     ]{.underline} |
|                       |           |            |                     |
|                       |    State, |            | [     ]{.underline} |
|                       |     Zip   |            |                     |
|                       |           |            | [     ]{.underline} |
|                       | Code) (If |            |                     |
|                       | ap        |            | [     ]{.underline} |
|                       | plicable: |            |                     |
|                       | Div/Unit, |            | [     ]{.underline} |
|                       | Rm #/ Sub |            |                     |
|                       | Unit)     |            |                     |
|                       |           |            |                     |
|                       | [         |            |                     |
|                       |      ]{.u |            |                     |
|                       | nderline} |            |                     |
|                       |           |            |                     |
|                       | [         |            |                     |
|                       |      ]{.u |            |                     |
|                       | nderline} |            |                     |
|                       |           |            |                     |
|                       | [         |            |                     |
|                       |      ]{.u |            |                     |
|                       | nderline} |            |                     |
|                       |           |            |                     |
|                       | E-MAIL    |            |                     |
|                       | ADDRESS   |            |                     |
|                       | (O        |            |                     |
|                       | ptional): |            |                     |
|                       |           |            |                     |
|                       |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| 4\. USDA AGENCY CODE  | 5\.       |            | 6\. WORK TELEPHONE  |
| (See Codes Below)     | EMPLOYEE  |            | NUMBER              |
|                       | SOCIAL    |            |                     |
|                       | SECURITY  |            |                     |
|                       | NUMBER    |            |                     |
|                       | (last 4   |            |                     |
|                       | numbers): |            |                     |
|                       |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| 7.  MODE (S) OF       | 8.  TYPE  |            | 9.  TYPE OF REDUCED |
|     TRANSPORTATION TO |     OF    |            |     FARE PUBLIC     |
|     BE USED DAILY TO  |     FARE  |            |     TRANSPORTATION  |
|     COMMUTE TO AND    |     MEDIA |            |     RATE YOU        |
|     FROM WORK.        |     YOU   |            |     RECEIVE.        |
|                       |     USE.  |            |                     |
| Bus Light Rail Subway |           |            | > Disability        |
|                       | Fare card |            | >                   |
| Ferry Train           | Tickets   |            | > Senior Citizen    |
| Authorized Vanpool    | Pass      |            |                     |
|                       |           |            |                     |
| Other (Specify)       | Tokens    |            |                     |
| [     ]{.underline}   | Voucher   |            |                     |
|                       |           |            |                     |
|                       | SmarTrip  |            |                     |
|                       | Card      |            |                     |
|                       |           |            |                     |
|                       | Other     |            |                     |
|                       | (         |            |                     |
|                       | Specify)[ |            |                     |
|                       |      ]{.u |            |                     |
|                       | nderline} |            |                     |
+-----------------------+-----------+------------+---------------------+
| 10\. Prior to         |           |            |                     |
| applying for this     |           |            |                     |
| benefit, how did you  |           |            |                     |
| commute to work       |           |            |                     |
| (Check One) Drive Bus |           |            |                     |
| Train Vanpool Ferry   |           |            |                     |
| Other                 |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| **EMPLOYEE            |           |            |                     |
| CERTIFICATION**       |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| **WARNING:** 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; Civil Penalty   |           |            |                     |
| Action, providing for |           |            |                     |
| administrative        |           |            |                     |
| recoveries of up to   |           |            |                     |
| \$10,000 per          |           |            |                     |
| violation; and/or     |           |            |                     |
| agency disciplinary   |           |            |                     |
| actions up to and     |           |            |                     |
| including removal     |           |            |                     |
| from Federal Service. |           |            |                     |
|                       |           |            |                     |
| -   I certify I am    |           |            |                     |
|     employed by the   |           |            |                     |
|     Department of     |           |            |                     |
|     Agriculture.      |           |            |                     |
|                       |           |            |                     |
| -   I certify I am    |           |            |                     |
|     eligible for a    |           |            |                     |
|     public            |           |            |                     |
|     transportation    |           |            |                     |
|     fare benefit. I   |           |            |                     |
|     will use it for   |           |            |                     |
|     my daily commute  |           |            |                     |
|     to and from work. |           |            |                     |
|     I will not give,  |           |            |                     |
|     sell, or transfer |           |            |                     |
|     it to anyone      |           |            |                     |
|     else.             |           |            |                     |
|                       |           |            |                     |
| -   I certify I am    |           |            |                     |
|     not a member of a |           |            |                     |
|     carpool. I do not |           |            |                     |
|     receive           |           |            |                     |
|     disability or     |           |            |                     |
|     executive parking |           |            |                     |
|     privileges.       |           |            |                     |
|                       |           |            |                     |
| -   I certify the     |           |            |                     |
|     monthly transit   |           |            |                     |
|     benefit I am      |           |            |                     |
|     receiving does    |           |            |                     |
|     not exceed my     |           |            |                     |
|     monthly commuting |           |            |                     |
|     costs.            |           |            |                     |
|                       |           |            |                     |
| -   I certify that in |           |            |                     |
|     any given month,  |           |            |                     |
|     I will not use    |           |            |                     |
|     the               |           |            |                     |
|                       |           |            |                     |
|   Government-provided |           |            |                     |
|     transit benefit   |           |            |                     |
|     in excess of the  |           |            |                     |
|     statutory limit.  |           |            |                     |
|     If my commuting   |           |            |                     |
|     costs per month   |           |            |                     |
|     on public         |           |            |                     |
|     transportation    |           |            |                     |
|     exceed the        |           |            |                     |
|     monthly statutory |           |            |                     |
|     limit, then I     |           |            |                     |
|     will continue to  |           |            |                     |
|     use public        |           |            |                     |
|     transportation    |           |            |                     |
|     and will          |           |            |                     |
|     supplement those  |           |            |                     |
|     additional costs  |           |            |                     |
|     with my own       |           |            |                     |
|     funds.            |           |            |                     |
|                       |           |            |                     |
| -   I certify I am    |           |            |                     |
|     responsible for   |           |            |                     |
|     returning ALL     |           |            |                     |
|     partially used    |           |            |                     |
|     and unused fare   |           |            |                     |
|     media to my       |           |            |                     |
|     agency's          |           |            |                     |
|     designated        |           |            |                     |
|     Commuter Benefit  |           |            |                     |
|     Coordinator three |           |            |                     |
|     working days      |           |            |                     |
|     before my         |           |            |                     |
|     effective date of |           |            |                     |
|     reassignment,     |           |            |                     |
|     transfer,         |           |            |                     |
|     resignation,      |           |            |                     |
|     retirement, etc.  |           |            |                     |
|                       |           |            |                     |
| -   I certify my      |           |            |                     |
|     usual monthly     |           |            |                     |
|     public            |           |            |                     |
|     transportation    |           |            |                     |
|     commuting costs   |           |            |                     |
|     (excluding any    |           |            |                     |
|     parking costs)    |           |            |                     |
|     are               |           |            |                     |
|                       |           |            |                     |
| \$[     ]{.underline} |           |            |                     |
|     (amount is taken  |           |            |                     |
|     from completed    |           |            |                     |
|     worksheet on back |           |            |                     |
|     page).            |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| 11. SIGNATURE OF      |           | 12\. DATE  |                     |
|     EMPLOYEE          |           |            |                     |
|                       |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| **VERIFICATION --     |           |            |                     |
| COMMUTER BENEFIT      |           |            |                     |
| COORDINATOR**         |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| 13. NAME OF COMMUTER  |           | 14. AGENCY |                     |
|     BENEFIT           |           |            |                     |
|     COORDINATOR       |           |    MAXIMUM |                     |
|                       |           |            |                     |
| > Mary Tjeerdsma      |           |    BENEFIT |                     |
| > 202-690-2524        |           |     (Enter |                     |
|                       |           |            |                     |
|                       |           |    monthly |                     |
|                       |           |            |                     |
|                       |           |    payable |                     |
|                       |           |     amount |                     |
|                       |           |     for    |                     |
|                       |           |     each   |                     |
|                       |           |     p      |                     |
|                       |           | articipant |                     |
|                       |           |     based  |                     |
|                       |           |     upon   |                     |
|                       |           |            |                     |
|                       |           |  commuting |                     |
|                       |           |     costs  |                     |
|                       |           |     and    |                     |
|                       |           |            |                     |
|                       |           |  statutory |                     |
|                       |           |     li     |                     |
|                       |           | mitations, |                     |
|                       |           |     agency |                     |
|                       |           |            |                     |
|                       |           |    policy, |                     |
|                       |           |     Union  |                     |
|                       |           |     Neg    |                     |
|                       |           | otiations, |                     |
|                       |           |     etc.). |                     |
|                       |           |            |                     |
|                       |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| 15. SIGNATURE OF      |           | 16. DATE   |                     |
|     COMMUTER BENEFIT  |           |            |                     |
|     COORDINATOR       |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| ###                   |           |            |                     |
| 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  |           |            |                     |
| transportation        |           |            |                     |
| 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.   |           |            |                     |
| This information will |           |            |                     |
| be provided to the    |           |            |                     |
| Department of         |           |            |                     |
| Transportation to     |           |            |                     |
| administer this       |           |            |                     |
| program and to ensure |           |            |                     |
| that you are not      |           |            |                     |
| listed as a carpool   |           |            |                     |
| participant or a      |           |            |                     |
| holder of any other   |           |            |                     |
| form of vehicle work  |           |            |                     |
| site parking permit   |           |            |                     |
| with USDA or any      |           |            |                     |
| other Federal Agency. |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| **AGENCY CODES**      |           |            |                     |
+-----------------------+-----------+------------+---------------------+
| ##### Office of the   |           |            |                     |
| Secretary 18 Economic |           |            |                     |
|  Research Svc 38 Offi |           |            |                     |
| ce of Chief Economist |           |            |                     |
|                       |           |            |                     |
| ##### Ag              |           |            |                     |
| ricultural Marketing  |           |            |                     |
| Svc 20 National Agric |           |            |                     |
| ultural Statistics Sv |           |            |                     |
| c 42 Office of Budget |           |            |                     |
|  and Program Analysis |           |            |                     |
|                       |           |            |                     |
| ##### 03              |           |            |                     |
|  Agricultural Researc |           |            |                     |
| h Svc 22 Cooperative  |           |            |                     |
| State Research, 90 Of |           |            |                     |
| fice of the Chief Fin |           |            |                     |
| ancial Officer {#agri |           |            |                     |
| cultural-research-svc |           |            |                     |
| -22-cooperative-state |           |            |                     |
| -research-90-office-o |           |            |                     |
| f-the-chief-financial |           |            |                     |
| -officer .unnumbered} |           |            |                     |
|                       |           |            |                     |
| ###### Rural Housing  |           |            |                     |
| Svc Education, and Ex |           |            |                     |
| tension Svc DA Depart |           |            |                     |
| mental Administration |           |            |                     |
|                       |           |            |                     |
| ##                    |           |            |                     |
| #### Risk Management  |           |            |                     |
| Agency 23 Office of I |           |            |                     |
| nspector General EO O |           |            |                     |
| ffice of Civil Rights |           |            |                     |
|                       |           |            |                     |
| ###### Forei          |           |            |                     |
| gn Agricultural Svc 3 |           |            |                     |
| 0 Food and Nutrition  |           |            |                     |
| Svc ES Office of the  |           |            |                     |
| Executive Secretariat |           |            |                     |
|                       |           |            |                     |
| ###### Fore           |           |            |                     |
| st Svc 32 Rural Busin |           |            |                     |
| ess-Cooperative Svc F |           |            |                     |
| A Farm Service Agency |           |            |                     |
|                       |           |            |                     |
| ###### Offi           |           |            |                     |
| ce of Communications  |           |            |                     |
| 34 Animal and Plant H |           |            |                     |
| ealth Inspection Svc  |           |            |                     |
| IT Office of the Chie |           |            |                     |
| f Information Officer |           |            |                     |
|                       |           |            |                     |
| ###### Office of Gen  |           |            |                     |
| eral Counsel 36 Grain |           |            |                     |
|  Inspection, Packers, |           |            |                     |
|  & Stockyards NA Nati |           |            |                     |
| onal Appeals Division |           |            |                     |
|                       |           |            |                     |
| ###### Rural Util     |           |            |                     |
| ities Svc Administrat |           |            |                     |
| ion SC National Sheep |           |            |                     |
|  Industry Improvement |           |            |                     |
|                       |           |            |                     |
| **16 Natural          |           |            |                     |
| Resources             |           |            |                     |
| Conservation Svc 37   |           |            |                     |
| Food Safety and       |           |            |                     |
| Inspection Svc        |           |            |                     |
| Center**              |           |            |                     |
+-----------------------+-----------+------------+---------------------+

**COMPLETE PUBLIC TRANSPORTATION BENEFIT EXPENSE WORK SHEET ON BACK**
**AD -1147 dated December 30, 2005 (Revised - other versions of form are
obsolete)**

+----------------+-----+---+------+-----+----+---+--------+---------+
| # 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** | # D |   | OF   |     | AI |   | PASS** | PASS**  |
|                | EPA |   | C    |     | LY |   |        |         |
|                | RTU |   | OMPA |     | E  |   | **EXP  | **EX    |
|                | RE  |   | NY** |     | XP |   | ENSE** | PENSE** |
|                | {#d |   |      |     | EN |   |        |         |
|                | epa |   |      |     | SE |   |        |         |
|                | rtu |   |      |     | ** |   |        |         |
|                | re  |   |      |     |    |   |        |         |
|                | .un |   |      |     |    |   |        |         |
|                | num |   |      |     |    |   |        |         |
|                | ber |   |      |     |    |   |        |         |
|                | ed} |   |      |     |    |   |        |         |
|                |     |   |      |     |    |   |        |         |
|                | ### |   |      |     |    |   |        |         |
|                | ### |   |      |     |    |   |        |         |
|                |  LO |   |      |     |    |   |        |         |
|                | CAT |   |      |     |    |   |        |         |
|                | ION |   |      |     |    |   |        |         |
|                |  {# |   |      |     |    |   |        |         |
|                | loc |   |      |     |    |   |        |         |
|                | ati |   |      |     |    |   |        |         |
|                | on  |   |      |     |    |   |        |         |
|                | .un |   |      |     |    |   |        |         |
|                | num |   |      |     |    |   |        |         |
|                | ber |   |      |     |    |   |        |         |
|                | ed} |   |      |     |    |   |        |         |
+----------------+-----+---+------+-----+----+---+--------+---------+
| 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 |        |         |
|                |     |   |      |     |    | h |        |         |
|                |     |   |      |     |    |   |        |         |
|                |     |   |      |     |    | \ |        |         |
|                |     |   |      |     |    | $ |        |         |
|                |     |   |      |     |    |   |        |         |
|                |     | x |      |     |    |   |        |         |
|                |     | 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 |      |     |    |   |        |         |
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+----------------+-----+---+------+-----+----+---+--------+---------+

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

*Metro Rail, Metro Bus and or Registered Vanpool*

Smart Benefits *Application*

![](media/image1.png)

Smart Benefits is an "electronic"way to receive your Metrochek transit
benefits. Your Metrochek benefits are electronically added each month to
your METRO registered SmartTrip card. The SmarTrip card is a permanent
plastic farecard that you register with METRO at the time of purchase
with your name, address and password.

##### Rules of Smart Benefits Participation {#rules-of-smart-benefits-participation .unnumbered}

1.  Any Federal employee who is a Metro Rail, Metro Bus or a registered
    Smart Benefits vanpool rider and are enrolled in a participating
    TranServe agency may join this Smart Benefits program.

2.  All Federal employees who participate in the SmartBenefits Program
    must authorize DOT to verify the accuracy of the name assigned to
    their SmarTrip Card.

3.  SmartBenefits are available to participating riders on a monthly
    basis.

4.  Vanpool benefits will be directly deposited into your specific
    vanpool operator's account monthly following the participant's one
    time on-line designated authorization at WMATA.com after this
    application is processed.

5.  SmartBenefits for rail and bus riders are available to recipients on
    a monthly basis to be claimed at any time during the month by
    downloading the benefit to their SmarTrip card at METRO Passes/Fare
    cards machines. Existing balances will remain on your card. Benefits
    may not be claimed for past or future month.

6.  Funds may not be removed from a SmarTrip card once they have added
    them to a SmarTrip account. If participants change agencies or leave
    Federal service it is their personal responsibility to financially
    complete their benefit obligations based on specific agency
    policies.

7.  Federal employees must have a **METRO REGISTERED** SmartTrip card
    and provide the serial number of the card. If you have not
    registered your card or are unsure that it is registered, you may do
    so by calling METRO at (202) 962-5719.

8.  All participants must provide a **[legible]{.underline}** photocopy
    of the **[back]{.underline}** of their registered SmarTrip card with
    their completed application.

9.  Applications must include all required information for program
    participation.

10. The Smartrip team will process applications, register Smartrip
    cards, and complete initial Vanpool participation registration
    through WMATA.com for all thoroughly completed applications.

11. **SmarTrip members MUST inform WMATA.com and the Smart Benefits team
    if they leave or change their registered vanpool before the end of
    the last month of riding. Riders are responsible for canceling
    vanpool participation**

If you don't currently have a SmarTrip card, you can purchase one via
mail, online, or at Metro's sales offices and area transit stores. **Be
sure to register it at time of purchase.**

*Metro Rail, Metro Bus and or Registered Vanpool*

Smart Benefits *Application*

![](media/image1.png)

###### Please answer the following questions {#please-answer-the-following-questions .unnumbered}

-   **What type of Mass Transportation do you use**

> **Metro Rail Metro Bus (SmarTrip reader installed) Registered
> Vanpool**

-   What Federal agency are you employed by [     ]{.underline}

**Van Pool
Operator/Company\_[     ]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Van Pool registration number with
WMATA\_     \_\_\_\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**All information required below must be clearly legible to assure
accurate data processing of program participation**

###  First /Last Name: [     ]{.underline} DOB: mm/dd/yy [     ]{.underline}\_\_\_\_\_\_\_ 

> **Work E-Mail Address:
> [     ]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **Address (must match Smartrip card registration address, including
> zip code)**
> **[     ]{.underline}**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **[     ]{.underline}**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Last Four SSN: [    ]{.underline} Work Phone: [     ]{.underline}**
>
> **Applicant Signature:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **Monthly Transit Cost [*NOT*]{.underline} including parking:
> \$\_[     ]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_­­­­­­­­­­­­­­**
>
> **Registered Smartrip card \#
> \_[     ]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **5 digit password for SmarTrip card registration in
> WMATA\_\_[     ]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Please attach a copy of the back of your SmarTrip card with the serial
number showing clearly with this application.

**To be filled out by**

**Agency Transit Coordinator**

**Authorizing
Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Admin Code\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Authorized Starting Month \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Authorized
Smart Benefit Subsidy 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.
This information will be matched with lists at other Federal agencies of
Government-assigned parking to ensure consistency with mode of
transportation checked.**