Form 0722 – Fill Out and Use This PDF

In box 1, enter the name of the applicant (Last, First, Middle Initial); in 2A, the full duty station address; in 2B, the home address.

In box 3, enter the organization code, which must be one of 23 codes listed.

In box 4, enter the payroll duty station no.; see IPCAP/ETA Service Record for correct code.

In box 5, enter the employee's last four social security no.'s.

In box 6, type of benefit, check one: direct subsidy (National Capital Regional Only) or field subsidy (All except National Capital Region).

In box 7, action requested, check one: add (New), change (Circle Item No. containing change) or withdraw.

In 8A, mark the mode(s) of transportation to be used to and from work: bus, ferry, light rail, subway, authorized vanpool, train or other (specify).

For field subsidy only, enter in 8B the name of the transit authority/company and in 8C the zone(s) (if applicable).

For field subsidy only, enter in 8D what type of media fare you require (tokens, vouchers, monthly pass tickets, denominations, preferred, etc.).

In box 9, check YES or NO: do you receive reduced fare public transportation rates (Employee with disabilities or Senior Citizen)?

In box 10, enter your scheduled tour of duty.

Certify that you are employed by the Department of Veterans Affairs and are not named on a Federally subsidized workplace parking permit with VA or any other Federal agency. Certify that you are eligible for a public transportation fare benefit, will use it for your daily commute to and/or from work, and will not transfer it to anyone else. Certify that the monthly transit benefit you are receiving does not exceed your monthly commuting costs. Certify that in any given month, you will not use the Government-provided transit benefit in excess of the statutory limit. If your commuting costs per month on public transit exceed the monthly statutory limit, then continue to use public transit and supplement those additional costs with your own funds. Certify that whenever you have usable transit benefits left over at the end of a distribution period due to leave or travel, you will reduce your next transit benefit by the amount of benefits you did not use during the previous distribution. Certify that your usual monthly public transit commuting costs (excluding any parking costs) are $ (rounded to the nearest dollar).

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. (checked November 12, 2026)

Enter the office telephone no. in box 11, sign in 12A (signature of employee) and enter the date in 12B.

The supervisor prints the name in 13A, enters the signature of the supervisor in 13B and enters the date in 13C.

The supervisor certifies that the 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 the supervisor's 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.

Verification - transit manager: in 14, enter the name of the transit manager; in 15, the location; in 16, the signature of the transit manager; in 17, the date.

For payroll office use only: 18. PAID INPUT COMPLETED and 19. DATE.

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.

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.

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.

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.

Converting daily and weekly cost to monthly cost, 40-hour workweek schedule conversion: eight hour work day conversion X 21, nine hour work day conversion X 19, ten hour work day conversion X 17.

Complete if you do not commute on a full time basis (part-time, telecommute, etc.): daily mass transit cost, number of days commuting to work per month, total monthly costs.

Enter your grand total monthly mass transit commuting costs rounded to the nearest dollar (Round either up or down to nearest dollar).

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.

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

On the mass transit expense work sheet, print your name clearly (name of employee) and sign (signature of employee).