Form 0722 PDF Details

Navigating the complexities of public transit fare benefits for government employees requires a thorough understanding of the VA Form 0722, an essential document designed to facilitate the application process for such advantages. Under the umbrella of Public Law 101-509, this application isn't just a formality; it stands as a gateway to economic and practical benefits for employees seeking support in their daily commute. By explicitly outlining personal details, employment information, and specific transit needs, applicants embark on a journey toward reduced commuting costs, provided they adhere to the stipulations regarding eligibility and accurate reporting of commuting expenses. The form itself, while voluntary, is central to ensuring that those who apply do not concurrently benefit from other federal commuting aid, such as carpool programs or vehicle worksite parking permits, thereby maintaining fairness and efficiency in the distribution of transit subsidies. Additionally, it emphasizes the importance of honesty and accuracy in reporting, given the legal repercussions for false certifications—a safeguard ensuring that the benefits serve those genuinely in need and in accordance with the program's guidelines. From listing various modes of transportation to certifying usage and cost, the VA Form 0722 intricately weaves through the requirements, ensuring every eligible employee can navigate the path to receiving their fare benefit with clarity and confidence.

QuestionAnswer
Form NameForm 0722
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva 0722, va form 0722, goe counsel 10c form, form 0722 transit benefit

Form Preview Example

APPLICATION FOR PUBLIC TRANSIT FARE BENEFIT

PRIVACY ACT STATEMENT: This information is solicited under authority of Public Law 101-509. 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 provided to the Department of Transportation to administer this program and to ensure that you are not listed as a carpool participant or a holder of any other form of vehicle worksite parking permit with VA or any other Federal agency.

NOTE: Items 1 through 12, and the reverse of this form, should be completed in full before submitting to your designated transit manager.

1. NAME OF APPLICANT (Last, First, Middle Initial)

2A. FULL DUTY STATION ADDRESS

2B. HOME ADDRESS

 

 

 

3. ORGANIZATION CODE

 

4. PAYROLL DUTY

5. EMPLOYEE'S LAST 6. TYPE OF BENEFIT (check one)

7. ACTION REQUESTED (check one)

 

 

 

STATION NO. (See

FOUR SOCIAL

 

 

DIRECT SUBSIDY (National

 

 

ADD (New)

 

 

 

 

 

 

(Must be one of 23 codes listed below)

 

IPCAP/ETA Service

SECURITY NO.'S

 

 

 

 

 

 

 

Capital Regional Only)

 

 

 

CHANGE (Circle Item No.

 

 

 

Record for correct

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

code)

 

 

 

 

 

FIELD SUBSIDY (All except

 

 

containing change)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Capital Region)

 

 

WITHDRAW

 

 

 

 

 

 

 

 

 

 

8A. MODE(S) OF TRANSPORTATION TO BE USED TO AND FROM WORK

 

ITEMS 8B, 8C, AND 8D, ARE FOR FIELD SUBSIDY ONLY

BUS

FERRY

OTHER (Specify below)

 

 

 

 

 

 

 

 

 

 

8B. NAME OF TRANSIT AUTHORITY/

8C. ZONE(S)

8D. WHAT TYPE OF MEDIA FARE DO

LIGHT RAIL

 

 

 

 

 

COMPANY

 

 

(If applicable)

YOU REQUIRE (Tokens, vouchers,

 

 

 

 

 

 

 

 

 

 

 

 

monthly pass tickets, denominations,

 

AUTHORIZED

 

 

 

 

 

 

 

 

 

 

 

preferred, etc.)

SUBWAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VANPOOL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRAIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. DO YOU RECEIVE REDUCED FARE PUBLIC TRANSPORTATION

 

10. SCHEDULED TOUR OF DUTY

 

 

 

 

 

 

 

 

 

RATES (Employee with disabilities or Senior Citizen)

YES

NO

 

 

 

 

 

 

 

AM

TO

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE CERTIFICATION

WARNING: This certification concerns a matter with 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 $10,000 per violation, and/or agency disciplinary actions up to and including removal from Federal Service.

I certify that I am employed by the Department of Veterans Affairs and am not named on a Federally subsidized workplace parking permit with VA or any other Federal agency.

I certify that I am eligible for a public transportation fare benefit, will use it for my daily commute to and/or from work, and will not transfer it to anyone else.

I certify that my monthly transit benefit I am receiving does not exceed my monthly commuting costs.

I certify that in any given month, I will not use the Government-provided transit benefit in excess of the statutory limit. If my commuting costs per month on public transit exceed the monthly statutory limit, then I will continue to use public transit and will supplement those additional costs with my own funds.

I certify that whenever I have usable transit benefits left over at the end of a distribution period due to leave or travel, I will reduce my next transit benefit by the amount of benefits I did not use during the previous distribution.

I certify that my usual monthly public transit commuting costs (excluding any parking costs) are $

 

(rounded to the nearest dollar).

 

 

 

11. OFFICE TELEPHONE NO.

12A. SIGNATURE OF EMPLOYEE

12B. DATE

SUPERVISOR CERTIFICATION

I certify that the above applicant is employed and paid by VA; is eligible for VA transit subsidy; and has read and understands all information contained in the Employee Certification Section of this application. To the best of my knowledge, the information provided in items 2A, 2B, 3, 4 and 10 is current; and that the applicant's work schedule qualifies the employee for the benefit requested on the Mass Transit Expense Work Sheet.

13A. PRINTED NAME OF SUPERVISOR

13B. SIGNATURE OF SUPERVISOR

13C. DATE

 

VERIFICATION - TRANSIT MANAGER

 

 

 

 

14. NAME OF TRANSIT MANAGER

 

15. LOCATION

 

 

 

 

16. SIGNATURE OF TRANSIT MANAGER

 

 

17. DATE

 

 

 

 

 

FOR PAYROLL OFFICE USE ONLY

18.PAID INPUT COMPLETED

ORGANIZATION CODES

19. DATE

(00)Office of the Secretary

(00CFM) Office of Acquisition, Logistics and Construction (GOE) (001AL) Office of Acquisition, Logistics and Construction (Supply Fund)

(01)Board of Veterans' Appeals

(02)General Counsel

(002)Assistant Secretary for Public & Intergovernmental Affairs

(004A) Assistant Secretary for Management (Finance Fund)

(004F) Assistant Secretary for Management (Franchise Fund)

(004G) Assistant Secretary for Management (GOE)

(005F) Assistant Secretary for Information & Technology (Franchise Fund)

(005G) Assistant Secretary for Information & Technology (GOE)

(006G) Assistant Secretary for Human Resources & Administration (GOE)

(007)Assistant Secretary for Operations, Security and Preparedness

(008)Assistant Secretary for Policy & Planning

(009)Assistant Secretary for Congressional & Legislative Affairs

(10C) Veterans Health Administration (Canteen Service)

(10E) Veterans Health Administration - (Medical Administration)

(10F) Veterans Health Administration - (Medical Facilities)

(10J) Veterans Health Administration - (FHCC)

(10M) Veterans Health Administration - (Medical Services)

(10R) Veterans Health Administration - (Research)

(20)Veterans Benefits Administration

(40)National Cemetery Administration

(50)Inspector General

VA FORM

0722

SUPERSEDES VA FORM 0722, APRIL 2011,

FEB 2012

WHICH WILL NOT BE USED.

MASS TRANSIT EXPENSE WORK SHEET

NOTE: The Application for Public Transit Fare Benefit, VA Form 0722, requires VA subsidy participants to calculate their usual monthly mass transit commuting cost for their daily commute to work. This work sheet must be completed to receive subsidy benefits and will assist employees in computing their usual monthly mass transit commuting cost to the nearest dollar.

INSTRUCTIONS: Calculate your Total Monthly Mass Transit Expenses by the way you pay for your commute. Use the daily column if you pay for transportation on a daily basis; the weekly column if you purchase weekly commuter tickets; or the monthly column if you purchase a monthly ticket or pass. It is possible that you may list costs in more than one column depending on the number of transportation modes you take and how you pay for them. Then, using the conversion section, convert all cost to total monthly costs to the nearest dollar amount.

REMEMBER: Parking fees are not allowed and cannot be included when computing monthly transit costs. If you are a person with a disability or a senior citizen receiving reduced fares rates, you must calculate the reduced fare rates that you pay.

 

 

 

MODE OF TRANSPORTATION

 

 

 

 

DAILY

 

WEEKLY PASS

MONTHLY PASS

 

 

 

 

 

 

EXPENSE

 

 

EXPENSE

 

 

EXPENSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUS TO WORK

 

 

 

 

NAME OF COMPANY

 

$

 

 

 

 

 

 

 

 

 

 

 

(Local)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUS FROM WORK

 

 

 

 

NAME OF COMPANY

 

$

 

 

 

$

 

 

 

$

 

 

 

(Local)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER BUS MODE TO WORK

 

NAME OF COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

(Commuter or County)

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER BUS MODE FROM WORK

NAME OF COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

(Commuter or County)

 

 

 

 

 

 

$

 

 

 

$

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RAIL TO WORK

 

 

 

 

FROM WHAT STATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

(Light Rail or Subway)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RAIL FROM WORK

 

 

 

 

FROM WHAT STATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

 

 

 

$

 

 

 

(Light Rail or Subway)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMUTER RAIL TO WORK

 

NAME OF COMPANY/STATION

$

 

 

 

 

 

 

 

 

 

 

 

(Train)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMUTER RAIL FROM WORK

NAME OF COMPANY/STATION

 

 

 

 

 

 

 

 

 

 

 

 

(Train)

 

 

 

 

 

 

 

 

 

$

 

 

 

$

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Specify)

 

 

 

 

 

 

NAME OF COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VAN POOL COST PER MONTH

NAME OF COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL

$

 

 

 

$

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONVERTING DAILY AND WEEKLY COST TO MONTHLY COST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40-HOUR WORKWEEK SCHEDULE CONVERSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIGHT HOUR WORK DAY CONVERSION

 

NINE HOUR WORK DAY CONVERSION

 

 

TEN HOUR WORK DAY CONVERSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAILY COST

 

NO. DAYS

 

TOTAL DAILY COST

 

DAILY COST

 

NO. DAYS

 

TOTAL DAILY COST

DAILY COST

NO. DAYS

 

TOTAL DAILY COST

 

 

 

WORKED

 

PER MONTH

 

 

 

 

WORKED

 

PER MONTH

 

 

 

WORKED

 

PER MONTH

$

 

 

X 21

 

$

 

 

$

 

 

X 19

 

 

 

 

 

$

 

X 17

 

$

 

 

 

PART TIME OR TELECOMMUTE CONVERSION

 

 

 

 

 

 

 

WEEKLY PASS CONVERSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete if you do not commute on a full time basis (part-time, telecommute, etc.)

 

 

 

WEEKLY PASS COSTS

NUMBER OF WEEKS

TOTAL WEEKLY COST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PER MONTH

 

PER MONTH

DAILY MASS TRANSIT COST

 

 

NUMBER OF DAYS COMMUTING

 

TOTAL MONTHLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO WORK PER MONTH

 

 

COSTS

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

X

 

 

 

 

$

 

 

 

$

 

 

 

X 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If the scheduled number of hours you work per month changes due to intermittent tours of duty, see your Transit Manager for possible self-certification options as prescribed in Transit Benefit Program Directive 0633.

NAME OF EMPLOYEE (Please print your name clearly)

 

 

 

TOTAL DAILY COST PER MONTH (if any)

$

 

 

 

 

TOTAL WEEKLY PASS COST PER MONTH (if any)

$

 

 

 

SIGNATURE OF EMPLOYEE

 

 

 

TOTAL MONTHLY PASS EXPENSE (if any)

$

 

 

 

 

GRAND TOTAL COST PER MONTH

$

 

 

 

MY GRAND TOTAL MONTHLY MASS TRANSIT COMMUTING COSTS ROUNDED TO THE NEAREST DOLLAR

 

(Round either up or down to nearest dollar)

$

 

 

 

NOTE: Employees are responsible for adjusting their monthly transit benefit each month in accordance with their actual commuting costs.

BACK OF VA FORM 0722, FEB 2012

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2. When this segment is completed, you have to insert the needed particulars in I certify that I am employed by, OFFICE TELEPHONE NO, A SIGNATURE OF EMPLOYEE, B DATE, I certify that the above applicant, A PRINTED NAME OF SUPERVISOR, B SIGNATURE OF SUPERVISOR, C DATE, SUPERVISOR CERTIFICATION, NAME OF TRANSIT MANAGER, LOCATION, VERIFICATION TRANSIT MANAGER, SIGNATURE OF TRANSIT MANAGER, PAID INPUT COMPLETED, and FOR PAYROLL OFFICE USE ONLY so you can progress to the 3rd stage.

FOR PAYROLL OFFICE USE ONLY, I certify that I am employed by, and SIGNATURE OF TRANSIT MANAGER in va intergovernmental 10c pdf

3. The following step is focused on EXPENSE, EXPENSE, EXPENSE, BUS TO WORK Local, BUS FROM WORK Local, OTHER BUS MODE TO WORK Commuter or, OTHER BUS MODE FROM WORK Commuter, RAIL TO WORK Light Rail or Subway, RAIL FROM WORK Light Rail or Subway, NAME OF COMPANY, NAME OF COMPANY, NAME OF COMPANY, NAME OF COMPANY, FROM WHAT STATION, and FROM WHAT STATION - fill out each of these fields.

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