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Get USDA AD-1147 2005

PUBLIC TRANSPORTATION BENEFIT EXPENSE WORK SHEET NOTE USDA Form AD-1147 Public Transportation Benefit Program Application requires USDA participants to calculate their usual monthly mass transit commuting cost to the nearest dollar for their daily commute to and from work. This work sheet must be completed to receive transit subsidy benefits. INSTRUCTIONS Calculate your total monthly mass transit expenses by the way you pay for your roundtrip daily commute to and from work. Using the work sheet below select your mode of mass transportation and identify the roundtrip cost based on how you pay i*e* daily weekly monthly for your fare media and convert all costs to a total monthly amount. REMINDER It is possible that an employee may have a combination of daily weekly or monthly expenses in computing his/her total monthly commuting costs. 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 rates you must calculate the reduced fare rate you pay. MODE OF TRANSPORTATION DEPARTURE LOCATION NAME OF COMPANY DAILY EXPENSE WEEKLY PASS MONTHLY Bus circle applicable Local - Commuter - County Rail circle applicable Light Rail - Subway Commuter Train Vanpool authorized Ferry Other Specify TOTAL COST CONVERTING DAILY AND WEEKLY COST TO MONTHLY COST 40 HOUR WORKWEEK SCHEDULE CONVERSION 8 HOUR WORK DAY CONVERSION Daily Cost No* Days Total Cost Worked Per Month x s 21 x s 19 x s 17 LESS THAN 40-HOUR WORKWEEK SCHEDULE CONVERSION Complete this section if your work schedule has you out of the official duty station location for less than 40 hours per week. i*e* telework part-time regularly scheduled travel etc* Daily Mass Transit Cost Number of Days Worked Per Month Total Daily Cost Per Month Weekly Mass Transit Cost x WEEKLY PASS CONVERSION If applicable Number of Weeks Per Month Total Weekly Cost Per Month x4 NOTE If the scheduled number of hours you work per month changes see your Commuter Benefit Coordinator for options. TOTAL MONTHLY COMMUTING COSTS TOTAL DAILY COST PER MONTH if applicable TOTAL WEEKLY COST PER MONTH if applicable GRAND TOTAL OF MONTHLY COMMUTING COSTS rounded to the nearest dollar. Transfer to front page under Employee Certification* EMPLOYEE CERTIFICATION NAME OF EMPLOYEEE Please print name SIGNATURE OF EMPLOYEE DATE SUPERVISOR CERTIFICATION OF WORK SCHEDULE NAME OF SUPERVISOR Please print name SIGNATURE OF SUPERVISOR BACK of AD - 1147 dated December 30 2005 Revised other versions of form obsolete. This work sheet must be completed to receive transit subsidy benefits. INSTRUCTIONS Calculate your total monthly mass transit expenses by the way you pay for your roundtrip daily commute to and from work. Using the work sheet below select your mode of mass transportation and identify the roundtrip cost based on how you pay i*e* daily weekly monthly for your fare media and convert all costs to a total monthly amount. Using the work sheet below select your mode of mass transportation and identify the roundtrip cost based on how you pay i*e* daily weekly monthly for your fare media and convert all costs to a total monthly amount. REMINDER It is possible that an employee may have a combination of daily weekly or monthly expenses in computing his/her total monthly commuting costs. .

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