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The Commuter Check program does not require any authorizations or certifications
to be signed by employees. However, some employers may require these forms in conjunction
with their payroll deduction process; to ensure that employees receiving Commuter
Checks are transit users; or to serve as a receipt. The following samples can be
modified to meet specific company needs.
Payroll Deduction Authorizations can be used to by employees to
authorize any salary reduction or payroll deduction to pay for Commuter Checks.
The forms can be used independently or combined with an employee certification form
(see below) to verify transit use.
Authorization version 1
In accordance with Section 132 (f) of the Internal Revenue Code, I authorize (company
name) to deduct $__________ from my monthly wages on a pre-tax basis (not to exceed
$110 per month) to be used to purchase Commuter Checks on my behalf.
Name: __________________________ Date: _____________________
Authorization version 2
I hereby authorize my employer to deduct $__________ from my monthly wages on a
pre-tax basis (not to exceed $110 per month) to be used for the purchase of Commuter
Checks consistent with provisions of Section 132 (f) of the Internal Revenue Code.
I will be using the benefit for commuting from home to work and return. I will not
give, barter, exchange, convey or otherwise transfer this benefit to any other person.
The monthly benefit that I receive does not exceed my average monthly commuting
cost for public transportation or eligible vanpool.
I understand and agree that false certification may result in disciplinary action
taken by my employer up to and including dismissal from employment and possible
prosecution for Federal income tax evasion.
Signed: _______________________Date: __________________
Commuter Check Employee Certifications can be used to ensure employees
receiving Commuter Checks are transit users, and to serve as a receipt. Versions
1 and 2 may be used for either the employer- paid or pre-tax approaches. Version
3 is for companies that provide Commuter Checks as an employer-paid benefit.
Certification version 1
I, ___________________________________, hereby certify that I regularly commute
to work at (company name) by public transportation.
I also agree that each Commuter Check which may be issued to me now or in the future
shall be redeemed solely in connection with my own monthly commute to work. I shall
not allow any Commuter Check to be redeemed by or used for the benefit of anyone
other than myself.
Name (print) ____________________________Employee Number ______
Signature _________________________Date_______________________
Commuter Check #(s) ___________Commuter Check Value: $__________
Transit operator(s) used__________________________________________
My signature above acknowledges receipt of the specified Commuter Check(s) on the
date indicated.
Certification version 2
I hereby acknowledge receipt of Commuter Check(s) in the amount of $_____.
I will be using this benefit for my regular daily commute from home to work and
return. I will not give, barter, exchange, convey or otherwise transfer this benefit
to any other person. The monthly benefit that I receive does not exceed my average
monthly commuting cost by public transportation or eligible vanpool.
I understand and agree that false certification may result in disciplinary action
taken by my employer up to and including dismissal from employment and possible
prosecution for federal income tax evasion.
Signature _________________________Date_______________________
Commuter Check #(s) ___________Commuter Check Value: $__________
Certification version 3
(Company name) is providing Commuter Checks as a tax-free mass transit subsidy to
employees who regularly commute to work by mass transit or vanpool. It is provided
as a monthly benefit. Employees who receive Commuter Checks are not eligible for
parking passes or reimbursement during the same period in which they receive Commuter
Checks. I have read the relevant eligibility criteria, certify I am eligible to
receive Commuter Checks, and acknowledge receipt of Commuter Checks as stated below.
Name (print) _______________________Employee Number ___________
Signature _________________________Date_______________________
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