DOC APPLICATION FOR TRANSIT BENEFIT
(Please Print)

Last_______________First________________M.I.___ Last 4 Digits of SSN#________ Grade/ Rank______
Address:____________________________________City_________State_____Zip Code_________
Agency: DOC Bureau: ITA Office________________________ ___________________
Building: HCHB Room Number________ Mail Stop_________ Phone #:_______________
PREVIOUS MODE OF TRANSPORTATION USED FOR COMMUTING: (Please check all that apply)

___Car (single or double occupancy, not including drive to Commuter Parking Lot)___Other_____________

___Car/Van Pool____Commuter Bus ___Commuter Train ____ Metro Bus ____Metro Rail

MASS TRANSIT BENEFIT MODE OF COMMUTING: (Please check all that apply)

___Commuter Bus ____Commuter Train ____Metro Bus ___Metro Rail ___ Metro- Approved Vanpool
EMPLOYEE CERTIFICATION: I HEREBY CERTIFY THAT I AM EMPLOYED BY THE DEPARTMENT OF COMMERCE (DOC) AND AM NOT NAMED ON A WORKSITE PARKING PERMIT WITH DOC OR ANY OTHER FEDERAL AGENCY. I ALSO CERTIFY THAT I AM ELIGIBLE FOR A PUBLIC TRANSPORTATION SUBSIDY BENEFIT, WILL BE USING IT FOR MY REGULAR DAILY COMMUTE TO AND/OR FROM WORK, AND WILL NOT TRANSFER IT TO ANYONE ELSE. IN ADDITION, I CERTIFY THAT THE MONTHLY TRANSIT BENEFIT I AM RECEIVING DOES NOT EXCEED MY AVERAGE MONTHLY COMMUTING COST (BASED ON A 20-DAY MONTH COMMUTING BY PUBLIC TRANSPORTATION).

THIS CERTIFICATION CONCERNS A MATTER WITHIN 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 $5000 PER VIOLATION, AND/OR AGENCY DISCIPLINARY ACTIONS UP TO AND INCLUDING DISMISSAL.

X ______________________________________________________________ __ __ (Applicant's Signature and Date)

PRIVACY ACT STATEMENT: This information is solicited under authority of 5 U.S. C. Sections 301 and 7905. 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 to ensure that you are not listed as a carpool or vanpool participant or a holder of any other form of vehicle work site parking permit with Department of Commerce or any other Federal agency.