Department of Social Services

Commuter Choice Program

Employee Yearly Certification

For the Calendar Year 20___

I hereby acknowledge receipt of a monthly transportation fringe benefit as indicated below from the Department of Social Services Commuter Choice Program, paid for by employer contributions and pre-tax deductions from my personal earnings, valued at: (please X appropriate selection)

Monthly / Semi-monthly / Routes
31.00 / 15.50 / GRTC Local Routes
53.00 / 26.50 / Route 19 Pemberton
53.00 / 26.50 / Exp Routes (23-25-26-27-28-29-64-66)
119.00 / 59.50 / Extended Exp. Routes 95
229.00 / 114.50 / Extended Exp. Route 81 & 82
50.00 / 25.00 / Van Pool Vouchers ($85)
55.00 / 27.50 / Van Pool Vouchers ($90)
60.00 / 30.00 / Van Pool Vouchers ($95)
75.00 / 37.50 / Van Pool Vouchers ($110)
85.00 / 42.50 / Van Pool Vouchers ($120)
90.00 / 45.00 / Van Pool Vouchers ($125)

I certify that during this period or until I terminate participation in the program, I used the benefits exclusively for my regular daily direct commute from home to work and return by public transportation or eligible vanpool, and that I did not give barter, exchange, convey, or otherwise transfer any of these benefits to any other person.

I further certify that the total of the monthly benefits that I received did not exceed my total commuting costs, excluding any parking costs, for the period I received them.

I further certify that during this period I did not receive any benefit under the Department of Social Services Employee Trip Reduction Program or any other similar transportation fringe benefit from any other agency, department, or division of the Commonwealth of Virginia, unless it was disclosed, in writing, to the Department of Social Services.

I understand and agree that false certification may result in disciplinary action taken by my agency, up to and including revocation of this transportation benefit, dismissal from employment, and/or may subject me to criminal prosecution under state or federal law.

Typed or Printed Name of Employee: ______

GRTC / Swipe Card # / Participation Effective Date:
Route # & Name
Van Pooling / Van # / Origin: / Destination: / Participation Effective Date:
Provider:
Participant Signature: / Date
Agency Parking Coordinator Signature: / Date:

NOTE: Each employee participating in the Department of Social Services Employee Trip Reduction Program should complete and sign a certification every December at or after receiving the December benefit. These certifications should be retained by the agency in its personnel files.

Commuter Choice Certification Form

032-35-0055-04-eng (07/14)