Access A Ride Nyc Application Form – Fill Out and Use This PDF

THE CITY OF NEW YORK COMMUTER BENEFITS PROGRAM

ACCESS-A-RIDE / PARATRANSIT PLAN

Submit completed form and required documentation to: Your Agency TransitBenefit Coordinator.

www.NYC.gov/payroll

www.getwageworks.com/nyc

IMPORTANT INFORMATION FOR EMPLOYEE

Your enrollment in the Commuter Benefits Program Access-A-Ride / Paratransit plan are provided as a pre-tax benefit contingent upon your eligibility for the MTA New York City Transit Access-A-Ride program or other paratransit program supported by other transit providers.

As proof of eligibility, copies (do not send the originals) of the following must be attached to this enrollment: MTA New York City Transit Access-A-Ride Acceptance Letter and Access-A-Ride Photo ID OR Proof of Enrollment in a Paratransit Service Program supported by other transit providers.

Two business days after you enroll in the Access-A-Ride Plan, go to www.wageworks.com or call WageWorks at 1-877-WageWorks (1-877-924-3967) Monday through Friday, from 8 a.m. to 8 p.m. Eastern Time, to select your coupons or tickets.

EMPLOYEE ACTION

EMPLOYEE IDENTIFICATION (All fields in this section are required and must be filled out completely. Please Print.)

Employee Reference #*
Name (First/Middle/Last)
Address Line 1				Address Line 2**
City/State/Zip
Email Address			Telephone
* Located on your pay statement or check stub.		** Apt.#, Fl.# or Box# if applicable.

ACCESS-A-RIDE / PARATRANSIT DEDUCTION AUTHORIZATION

SUSPEND ACCESS-A-RIDE / PARATRANSIT DEDUCTION

Submit at least 2 weeks before you want to suspend your deduction. Please note this will only suspend your payroll deduction. To also suspend your Access-A-Ride or other paratransit service orders you must do so directly with Wageworks at www.wageworks.com or 1-877-924-3967.

MONTH DAY	YEAR	MONTH DAY	YEAR
PAY DATE TO SUSPEND DEDUCTION		PAY DATE TO RESUME DEDUCTION

EMPLOYEE CERTIFICATION

I hereby authorize the City of New York to deposit my payroll deduction as indicated above into my WageWorks Commuter Benefits Transit Account.

I also grant authorization for the reversal of a credit to my account in the event the credit was made in error. I understand that, under the “National Automated Clearing House Association” operating guidelines and rules, the City of New York can only reverse the amount of the incorrect direct deposit.

I understand that participation in the Access-A-Ride program is contingent upon my qualification for MTA New York City Transit Access-A-Ride Paratransit Service or other qualified Paratransit Service. Proof of such eligibility must be provided as a condition of enrollment.

I understand, according to the Internal Revenue Code, that the average monthly amount of my transportation deductions should not exceed my average monthly cost of public transportation to and from work. If my average monthly cost of public transportation to and from work should change, I will change my deduction plan to accommodate my new circumstance. Furthermore, no reimbursement will be provided for pre-tax transportation fringe deductions. Upon cancellation, voluntary or otherwise, any funds remaining in my Commuter Benefits account will be available for use within the commuter account for a period of 90 days from the effective date of cancellation. Residual funds remaining in the account beyond the 90 day period will be forfeited.

I understand that $3.05 per month, to cover administrative costs of the program, will be paid by the City of New York to WageWorks on my behalf and will be added to my taxable earnings as a fringe benefit each month my account is debited for purchases and/or charges. The administrative charge is non-reversible.

I grant authorization for the City of New York to provide my enrollment information, including mailing address, phone number and e-mail address to WageWorks for uses exclusively related to the administration of the program.

I understand that this authorization will remain in effect until I submit a new request for a change or cancellation.

I understand that my Commuter Benefits Transit Account balance and information will be maintained by WageWorks. Paratransit Service coupons or vouchers must be ordered directly through WageWorks. Transit Account order processing and balance information is accessible online at www.wageworks.com or by calling WageWorks Customer Service at 1-877-WageWorks (1-877-924-3967).

MONTH DAY YEAR

Employee Signature

DATE

AGENCY PAYROLL SECTION

WW-4056-CNY-ACCESS-A-RIDE-FORM (Nov 2010)