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TRANSITCHEK ENROLLMENT FORM FORMS DUE by February 20 May 20 August 20 and November 20 NO EXCEPTIONS GRANTED ENROLLMENT CANCELLATION CHANGE Employee Information Name Department Social Security Number I elect to participate in the TransitChek program. I understand that the amount I have selected will be deducted from my paycheck before tax. Debit Card Information Debit cards are used to purchase MetroCards PATH QuickCards LIRR NJ Transit MetroNorth and many rail and bus passes or tickets. Debit Cards are available in the following increments up to a maximum of 120 per month. Please circle the card value or combination of cards up to 120 you wish to purchase. 30 35 45 50 55 60 65 104 110 115 120 Your Approval I authorize the payroll deductions from my salary monthly semi-monthly or weekly to equal the amount indicated above in exchange for the type of benefit indicated above. I understand that the payroll deduction will be made on a pre-tax basis. I hereby certify that I am using these products for my personal work-related commuting need thereby qualifying these expenses as tax-free. I further confirm my understanding that the above selected products cannot be returned or exchanged and understand that Sarah Lawrence College may amend or terminate this program at any time. After the initial enrollment period I will have the opportunity to stop or change the amount to be deducted during the Last 10 Days of February May August November and I must notify the Human Resources Department in writing using this enrollment form* I may not re-enroll in the program until the next enrollment date. Debit Card Information Debit cards are used to purchase MetroCards PATH QuickCards LIRR NJ Transit MetroNorth and many rail and bus passes or tickets. Debit Cards are available in the following increments up to a maximum of 120 per month. Please circle the card value or combination of cards up to 120 you wish to purchase. Debit Cards are available in the following increments up to a maximum of 120 per month. Please circle the card value or combination of cards up to 120 you wish to purchase. 30 35 45 50 55 60 65 104 110 115 120 Your Approval I authorize the payroll deductions from my salary monthly semi-monthly or weekly to equal the amount indicated above in exchange for the type of benefit indicated above. 30 35 45 50 55 60 65 104 110 115 120 Your Approval I authorize the payroll deductions from my salary monthly semi-monthly or weekly to equal the amount indicated above in exchange for the type of benefit indicated above. I understand that the payroll deduction will be made on a pre-tax basis. I hereby certify that I am using these products for my personal work-related commuting need thereby qualifying these expenses as tax-free. I understand that the payroll deduction will be made on a pre-tax basis. I hereby certify that I am using these products for my personal work-related commuting need thereby qualifying these expenses as tax-free. I further confirm my understanding that the above selected products cannot be returned or exchanged and understand that Sarah Lawrence College may amend or terminate this program at any time.

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