Fillable Army Mass Transportation Benefit Program Application Form printable pdf download

Army Mass Transportation Benefit Program Application Form

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Effective Date 1 October 2010

Print Form

ARMY MASS TRANSPORTATION BENEFIT PROGRAM

Outside the National Capital Region

Application Form

Please check one:

New Enrollment

Change Request (what change?)

Re-Enrolling

Withdrawing (effective date)

I. Applicant Information:

Last Name:

First Name:

MI:

Last Four SSN:

Residence City:

Residence State:

Residence 9-digit ZIP Code:

Organization/Command:

Installation/Activity:

Duty Location (city, state, 9-digit ZIP code):

Office Telephone (include area code):

E-mail Address:

Supervisor Name, Location, Office Telephone (include area code):

Employment type (please check only one):

Army Active Duty Officer

Army National Guard Active Duty Officer

Army Reserve Active Duty Officer

Army Active Duty Enlisted

Army National Guard Active Duty Enlisted

Army Reserve Active Duty Enlisted

Army Civilian Employee

Army National Guard Civilian/Mil Tech Employee

Army Reserve Civilian Employee

Army Nonappropriated Fund Employee - Please provide 9-digit Standard NAFI Number:

II. Applicant Certification: Please read and initial each item.

I certify that I understand that I am employed by the U.S. Department of the Army as a military member, civilian

employee or non-appropriated fund employee. My claim for benefits is as a Federal employee or military service

member, and not as a contract employee.

I certify that I understand that I am eligible for a public transportation fare benefit, will only use it for my daily

commute to and from work, will not transfer it to anyone else, and will not allow anyone else to use it.

I certify that I understand that the mode of transportation for which I am claiming the mass transportation

benefit is a qualified means of transportation.

I certify that I understand that the monthly transportation benefit I am claiming does not exceed my monthly

commuting costs.

I certify that I understand that I will not include parking costs, tolls, or the cost of "holding" a space in a vanpool

when calculating and claiming my monthly commuting costs.

I certify that I understand that I will adjust the amount received based upon extended absence (e.g. leave, TDY or

deployment).

I certify that I understand that I will notify my local MTBP Program Manager of any changes in my status, e.g.

name change, home or work address, change in commuting pattern or cost, or change in duty location or

employing organization, even if within the Army.

I certify that I understand that upon separation from the MTPB, I will return unused fare media to my local MTBP

Program Manager. If I have used the fare media for other purposes or converted the fare media to another form

of media, I will reimburse the Army by check or money order payable to the U.S. Treasury.

Army Mass Transportation Benefit Program Application Form

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