+-----------------------+-----------+-----------+-----------------------+
| # DEPA                |           |           |                       |
| RTMENT OF AGRICULTURE |           |           |                       |
|                       |           |           |                       |
| # PUBLIC              |           |           |                       |
| TRANSPORTATION BENEFI |           |           |                       |
| T PROGRAM APPLICATION |           |           |                       |
|                       |           |           |                       |
| (Please type or print |           |           |                       |
| legibly in blue or    |           |           |                       |
| black ink)            |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| ####### AC            |           |           |                       |
| TION REQUESTED (CHECK |           |           |                       |
|  ONE): \_\_\_New \_\_ |           |           |                       |
| \_Change \_\_\_Cancel |           |           |                       |
| lation \_\_\_Recertif |           |           |                       |
| ication Temporary NTE |           |           |                       |
|  DATE: \_\_\_\_\_\_\_ |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| 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, |           |                       |
|                       |           |           |                       |
|                       |    State, |           |                       |
|                       |     Zip   |           |                       |
|                       |           |           |                       |
|                       | Code) (If |           |                       |
|                       | ap        |           |                       |
|                       | plicable: |           |                       |
|                       | Div/Unit, |           |                       |
|                       | Rm #/ Sub |           |                       |
|                       | Unit)     |           |                       |
|                       |           |           |                       |
|                       | 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 RECEIVE. |
|     FROM WORK.        |     YOU   |           |                       |
|                       |     USE.  |           | > \_\_\_Disability    |
| \_\_\_Bus \_\_\_Light |           |           | >                     |
| Rail \_\_\_ Subway    | \         |           | > \_\_\_Senior        |
|                       | _\_\_Fare |           | > Citizen             |
| \_\_\_Ferry           | card      |           |                       |
| \_\_\_Train           | \_\_      |           |                       |
| \_\_\_Authorized      | \_Tickets |           |                       |
| Vanpool               | \         |           |                       |
|                       | _\_\_Pass |           |                       |
| \_\_\_Other (Specify) |           |           |                       |
| \_\_\_\_\_\_\_\_\     | \_\       |           |                       |
| _\_\_\_\_\_\_\_\_\_\_ | _\_Tokens |           |                       |
|                       | \_        |           |                       |
|                       | \_Voucher |           |                       |
|                       |           |           |                       |
|                       | \_\_\     |           |                       |
|                       | _SmarTrip |           |                       |
|                       | Card      |           |                       |
|                       |           |           |                       |
|                       | \_        |           |                       |
|                       | \_\_Other |           |                       |
|                       | (Specify) |           |                       |
|                       | \_\_      |           |                       |
|                       | \_\_\_\_\ |           |                       |
|                       | _\_\_\_\_ |           |                       |
|                       | \_\_\_\_\ |           |                       |
|                       | _\_\_\_\_ |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| 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               |           |           |                       |
|     \$\_\_\_\_        |           |           |                       |
| \_\_\_\_\_\_\_(amount |           |           |                       |
|     is taken from     |           |           |                       |
|     completed         |           |           |                       |
|     worksheet on back |           |           |                       |
|     page).            |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| 11. SIGNATURE OF      |           | 12\. DATE |                       |
|     EMPLOYEE          |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| **VERIFICATION --     |           |           |                       |
| COMMUTER BENEFIT      |           |           |                       |
| COORDINATOR**         |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| 13\. NAME OF COMMUTER |           | 1         |                       |
| BENEFIT COORDINATOR   |           | 4. AGENCY |                       |
|                       |           |           |                       |
|                       |           |   MAXIMUM |                       |
|                       |           |           |                       |
|                       |           |   BENEFIT |                       |
|                       |           |           |                       |
|                       |           |    (Enter |                       |
|                       |           |           |                       |
|                       |           |   monthly |                       |
|                       |           |           |                       |
|                       |           |   payable |                       |
|                       |           |           |                       |
|                       |           |    amount |                       |
|                       |           |     for   |                       |
|                       |           |     each  |                       |
|                       |           |     pa    |                       |
|                       |           | rticipant |                       |
|                       |           |     based |                       |
|                       |           |     upon  |                       |
|                       |           |           |                       |
|                       |           | commuting |                       |
|                       |           |     costs |                       |
|                       |           |     and   |                       |
|                       |           |           |                       |
|                       |           | statutory |                       |
|                       |           |     lim   |                       |
|                       |           | itations, |                       |
|                       |           |           |                       |
|                       |           |    agency |                       |
|                       |           |           |                       |
|                       |           |   policy, |                       |
|                       |           |     Union |                       |
|                       |           |     Nego  |                       |
|                       |           | tiations, |                       |
|                       |           |           |                       |
|                       |           |    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 |           |           |                       |
|                       |           |           |                       |
| ##### Agricultural    |           |           |                       |
| Research Svc 22 Coope |           |           |                       |
| rative State Research |           |           |                       |
| , 90 Office of the Ch |           |           |                       |
| ief Financial Officer |           |           |                       |
|                       |           |           |                       |
| ###### 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      |       |     |     |    |    |   |        |        |
| T             |       |     |     |    |    |   |        |        |
| RANSPORTATION |       |     |     |    |    |   |        |        |
| BENEFIT       |       |     |     |    |    |   |        |        |
| EXPENSE WORK  |       |     |     |    |    |   |        |        |
| SHEET**       |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **NOTE:**     |       |     |     |    |    |   |        |        |
| USDA Form     |       |     |     |    |    |   |        |        |
| AD-1147,      |       |     |     |    |    |   |        |        |
| Public        |       |     |     |    |    |   |        |        |
| T             |       |     |     |    |    |   |        |        |
| ransportation |       |     |     |    |    |   |        |        |
| 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           |       |     |     |    |    |   |        |        |
| from          |       |     |     |    |    |   |        |        |
| ]{.underline} |       |     |     |    |    |   |        |        |
| work. This    |       |     |     |    |    |   |        |        |
| work sheet    |       |     |     |    |    |   |        |        |
| must be       |       |     |     |    |    |   |        |        |
| completed to  |       |     |     |    |    |   |        |        |
| receive       |       |     |     |    |    |   |        |        |
| transit       |       |     |     |    |    |   |        |        |
| subsidy       |       |     |     |    |    |   |        |        |
| benefits.     |       |     |     |    |    |   |        |        |
|               |       |     |     |    |    |   |        |        |
| **IN          |       |     |     |    |    |   |        |        |
| STRUCTIONS:** |       |     |     |    |    |   |        |        |
| 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          |       |     |     |    |    |   |        |        |
| t             |       |     |     |    |    |   |        |        |
| ransportation |       |     |     |    |    |   |        |        |
| 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     | 1.    |     | **N |    | *  |   | **     | **M    |
| TRA           |   **D |     | AME |    | *D |   | WEEKLY | ONTHLY |
| NSPORTATION** | EPART |     | OF  |    | AI |   | PASS** | PASS** |
|               | URE** |     | COM |    | LY |   |        |        |
|               |       |     | PAN |    | E  |   | **EXP  | **EXP  |
|               | ```{= |     | Y** |    | XP |   | ENSE** | ENSE** |
|               | html} |     |     |    | EN |   |        |        |
|               | <!-   |     |     |    | SE |   |        |        |
|               | - --> |     |     |    | ** |   |        |        |
|               | ```   |     |     |    |    |   |        |        |
|               | 7     |     |     |    |    |   |        |        |
|               | .  ** |     |     |    |    |   |        |        |
|               | LOCAT |     |     |    |    |   |        |        |
|               | ION** |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Bus (circle   |       |     |     |    | \$ |   | \$     | \$     |
| applicable)   |       |     |     |    |    |   |        |        |
|               |       |     |     |    |    |   |        |        |
| Local -       |       |     |     |    |    |   |        |        |
| Commuter -    |       |     |     |    |    |   |        |        |
| County        |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Rail (circle  |       |     |     |    | \$ |   | \$     | \$     |
| applicable)   |       |     |     |    |    |   |        |        |
|               |       |     |     |    |    |   |        |        |
| Light Rail -  |       |     |     |    |    |   |        |        |
| Subway        |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Commuter      |       |     |     |    | \$ |   | \$     | \$     |
| Train         |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Vanpool       |       |     |     |    | \$ |   | \$     | \$     |
| (authorized)  |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Ferry         |       |     |     |    | \$ |   | \$     | \$     |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Other         |       |     |     |    | \$ |   | \$     | \$     |
| (Specify)     |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **TOTAL       |       |     |     |    | \$ |   | \$     | \$     |
| COST**        |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **CONVERTING  |       |     |     |    |    |   |        |        |
| DAILY AND     |       |     |     |    |    |   |        |        |
| WEEKLY COST   |       |     |     |    |    |   |        |        |
| TO MONTHLY    |       |     |     |    |    |   |        |        |
| COST**        |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **40 HOUR     |       |     |     |    |    |   |        |        |
| WORKWEEK      |       |     |     |    |    |   |        |        |
| SCHEDULE      |       |     |     |    |    |   |        |        |
| CONVERSION**  |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **8 HOUR WORK |       | **9 |     |    |    | * |        |        |
| DAY           |       | H   |     |    |    | * |        |        |
| CONVERSION**  |       | OUR |     |    |    | 1 |        |        |
|               |       | W   |     |    |    | 0 |        |        |
|               |       | ORK |     |    |    | H |        |        |
|               |       | DAY |     |    |    | O |        |        |
|               |       | CON |     |    |    | U |        |        |
|               |       | VER |     |    |    | R |        |        |
|               |       | SIO |     |    |    | W |        |        |
|               |       | N** |     |    |    | O |        |        |
|               |       |     |     |    |    | R |        |        |
|               |       |     |     |    |    | K |        |        |
|               |       |     |     |    |    | D |        |        |
|               |       |     |     |    |    | A |        |        |
|               |       |     |     |    |    | Y |        |        |
|               |       |     |     |    |    | C |        |        |
|               |       |     |     |    |    | O |        |        |
|               |       |     |     |    |    | N |        |        |
|               |       |     |     |    |    | V |        |        |
|               |       |     |     |    |    | E |        |        |
|               |       |     |     |    |    | R |        |        |
|               |       |     |     |    |    | S |        |        |
|               |       |     |     |    |    | I |        |        |
|               |       |     |     |    |    | O |        |        |
|               |       |     |     |    |    | N |        |        |
|               |       |     |     |    |    | * |        |        |
|               |       |     |     |    |    | * |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Daily Cost    |       | Da  |     |    |    | D |        |        |
| No. Days      |       | ily |     |    |    | a |        |        |
| Total Cost    |       | C   |     |    |    | i |        |        |
|               |       | ost |     |    |    | l |        |        |
| Worked Per    |       | No. |     |    |    | y |        |        |
| Month         |       | D   |     |    |    | C |        |        |
|               |       | ays |     |    |    | o |        |        |
| \$ x's 21 \$  |       | To  |     |    |    | s |        |        |
|               |       | tal |     |    |    | t |        |        |
|               |       | C   |     |    |    | N |        |        |
|               |       | ost |     |    |    | o |        |        |
|               |       |     |     |    |    | . |        |        |
|               |       | Wor |     |    |    | D |        |        |
|               |       | ked |     |    |    | a |        |        |
|               |       | Per |     |    |    | y |        |        |
|               |       | Mo  |     |    |    | s |        |        |
|               |       | nth |     |    |    | T |        |        |
|               |       |     |     |    |    | o |        |        |
|               |       | \$  |     |    |    | t |        |        |
|               |       | x's |     |    |    | a |        |        |
|               |       | 19  |     |    |    | l |        |        |
|               |       | \$  |     |    |    | C |        |        |
|               |       |     |     |    |    | o |        |        |
|               |       |     |     |    |    | s |        |        |
|               |       |     |     |    |    | t |        |        |
|               |       |     |     |    |    |   |        |        |
|               |       |     |     |    |    | W |        |        |
|               |       |     |     |    |    | o |        |        |
|               |       |     |     |    |    | r |        |        |
|               |       |     |     |    |    | k |        |        |
|               |       |     |     |    |    | e |        |        |
|               |       |     |     |    |    | d |        |        |
|               |       |     |     |    |    | P |        |        |
|               |       |     |     |    |    | e |        |        |
|               |       |     |     |    |    | r |        |        |
|               |       |     |     |    |    | M |        |        |
|               |       |     |     |    |    | o |        |        |
|               |       |     |     |    |    | n |        |        |
|               |       |     |     |    |    | t |        |        |
|               |       |     |     |    |    | h |        |        |
|               |       |     |     |    |    |   |        |        |
|               |       |     |     |    |    | \ |        |        |
|               |       |     |     |    |    | $ |        |        |
|               |       |     |     |    |    | x |        |        |
|               |       |     |     |    |    | ' |        |        |
|               |       |     |     |    |    | s |        |        |
|               |       |     |     |    |    | 1 |        |        |
|               |       |     |     |    |    | 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    |       | Num |     |    |    | T |        |        |
| Transit Cost  |       | ber |     |    |    | o |        |        |
|               |       | of  |     |    |    | t |        |        |
| \$            |       | D   |     |    |    | a |        |        |
|               |       | ays |     |    |    | l |        |        |
|               |       | Wor |     |    |    | D |        |        |
|               |       | ked |     |    |    | a |        |        |
|               |       | Per |     |    |    | i |        |        |
|               |       | Mo  |     |    |    | l |        |        |
|               |       | nth |     |    |    | y |        |        |
|               |       |     |     |    |    | C |        |        |
|               |       | x   |     |    |    | o |        |        |
|               |       |     |     |    |    | s |        |        |
|               |       |     |     |    |    | t |        |        |
|               |       |     |     |    |    | P |        |        |
|               |       |     |     |    |    | e |        |        |
|               |       |     |     |    |    | r |        |        |
|               |       |     |     |    |    | M |        |        |
|               |       |     |     |    |    | o |        |        |
|               |       |     |     |    |    | n |        |        |
|               |       |     |     |    |    | t |        |        |
|               |       |     |     |    |    | h |        |        |
|               |       |     |     |    |    |   |        |        |
|               |       |     |     |    |    | \ |        |        |
|               |       |     |     |    |    | $ |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **WEEKLY PASS |       |     |     |    |    |   |        |        |
| CONVERSION    |       |     |     |    |    |   |        |        |
| (If           |       |     |     |    |    |   |        |        |
| applicable)** |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| Weekly Mass   |       | Num |     |    |    | T |        |        |
| Transit Cost  |       | ber |     |    |    | o |        |        |
|               |       | of  |     |    |    | t |        |        |
| \$            |       | We  |     |    |    | a |        |        |
|               |       | eks |     |    |    | l |        |        |
|               |       | Per |     |    |    | W |        |        |
|               |       | Mo  |     |    |    | e |        |        |
|               |       | nth |     |    |    | e |        |        |
|               |       |     |     |    |    | k |        |        |
|               |       | x 4 |     |    |    | l |        |        |
|               |       |     |     |    |    | y |        |        |
|               |       |     |     |    |    | C |        |        |
|               |       |     |     |    |    | o |        |        |
|               |       |     |     |    |    | s |        |        |
|               |       |     |     |    |    | t |        |        |
|               |       |     |     |    |    | P |        |        |
|               |       |     |     |    |    | e |        |        |
|               |       |     |     |    |    | r |        |        |
|               |       |     |     |    |    | M |        |        |
|               |       |     |     |    |    | o |        |        |
|               |       |     |     |    |    | n |        |        |
|               |       |     |     |    |    | t |        |        |
|               |       |     |     |    |    | h |        |        |
|               |       |     |     |    |    |   |        |        |
|               |       |     |     |    |    | \ |        |        |
|               |       |     |     |    |    | $ |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **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      |       |     |     |    |    |   |        |        |
| Cer           |       |     |     |    |    |   |        |        |
| tification.** |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **EMPLOYEE    |       |     |     |    |    |   |        |        |
| CE            |       |     |     |    |    |   |        |        |
| RTIFICATION** |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **NAME OF     |       | **  |     |    |    | * |        |        |
| EMPLOYEEE     |       | SIG |     |    |    | * |        |        |
| (Please print |       | NAT |     |    |    | D |        |        |
| name)**       |       | URE |     |    |    | A |        |        |
|               |       | OF  |     |    |    | T |        |        |
|               |       | E   |     |    |    | E |        |        |
|               |       | MPL |     |    |    | * |        |        |
|               |       | OYE |     |    |    | * |        |        |
|               |       | E** |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **SUPERVISOR  |       |     |     |    |    |   |        |        |
| CERTIFICATION |       |     |     |    |    |   |        |        |
| OF WORK       |       |     |     |    |    |   |        |        |
| SCHEDULE**    |       |     |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+
| **NAME OF     |       | **  |     |    |    | * |        |        |
| SUPERVISOR    |       | SIG |     |    |    | * |        |        |
| (Please print |       | NAT |     |    |    | D |        |        |
| name)**       |       | URE |     |    |    | A |        |        |
|               |       | OF  |     |    |    | T |        |        |
|               |       | SUP |     |    |    | E |        |        |
|               |       | ERV |     |    |    | * |        |        |
|               |       | ISO |     |    |    | * |        |        |
|               |       | R** |     |    |    |   |        |        |
+---------------+-------+-----+-----+----+----+---+--------+--------+