Dpa 681 Form – Fill Out and Use This PDF

STATE OF CALIFORNIA

PRE-TAX PARKING/THIRD-PARTY ADMINISTRATOR/REIMBURSABLE ACCOUNT CLAIM

DPA 681 (12-01)

INSTRUCTIONS: After entering your name, phone number, social security number, and mailing address, enter the date(s) of parking and an official receipt that covers the date(s) claimed. List the parking provider name for each receipt and the amount claimed, which matches the receipted amount. See privacy notice below.

PARKING CLAIMED PURSUANT TO INTERNAL REVENUE CODE (IRSC) SECTION 132

(CANNOT EXCEED THE FEDERAL LIMITS CONTAINED IN IRSC SECTION 132)

*Claims for different months CANNOT be entered on the same line. Enter parking costs for different months on different lines, and attach additional pages, if necessary. Send completed form with copies of supporting documentation to: ASI, P.O. Box 6044, Columbia, MO 65205-6044.

READ CAREFULLY BEFORE SIGNING BELOW: I certify that all expenses for which I claim reimbursement were incurred during and related to my State employment during a period while I was enrolled under the Pre-Tax Parking Program, with respect to such expenses, and that the expenses have not been reimbursed nor are reimbursable from any other source. I fully understand that I am solely responsible for the sufficiency, accuracy, and veracity of all information relating to this claim, which I provide, and that all expenses for which reimbursement is claimed are proper expenses under Internal Revenue Code (IRSC) Section 132 and the State Pre-Tax Parking Program, and that I will be liable for payment of all related taxes and/or penalties thereon, including any federal, State, or city income taxes on amounts paid from the Program, which relate to such expense and were judged to be not eligible for reimbursement.

PRIVACY NOTICE: The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals. The State Controller’s Office and the plan administrator use information on this form for the purposes of identification and document processing. It is mandatory to furnish all information requested on this form. Failure to provide mandatory information may result in the claim not being processed, nonpayment of the claim, or the claim being processed incorrectly. The State Controller’s Office requires an employee’s social security number and name for identification purposes. Legal references authorizing maintenance of this information include Government Code Sections 1151 and 1153; Sections 6011 and 6051 of the Internal Revenue Code (IRSC); and Regulation 4, Section 404.1256, Code of Federal Regulations, under Section 218, Title II of the Social Security Act.