Monthly Transit Pass Payroll Deduction

Northwest Regional Education Service District

Enrollment Form

Please return your completed form to the Communications Department

Northwest Regional Education Service District employees have the option of paying for monthly transit passes using pre-tax income.

·  The cost of the pass will be deducted before taxes from your paycheck each month, reducing your taxable income by the amount of the pass; realizing an approx. six percent savings.

·  Passes will be available for pick up in the Communications Dept. around the 22nd of each month.

To enroll in the program: Please complete and sign this form and return it to the Communications Dept. (, 503-614-1252), authorizing Northwest Regional ESD to make the payroll deduction and to adjust for fare increases.

If you wish to make changes to the transit pass payroll deduction use this form as well. All new enrollments and all changes must be in accordance with printed deadlines on next page.

Select box that applies:

Initiating a new pre-tax transit pass enrollment

Changing my enrollment

Discontinuing my enrollment

Name: / Eff. Date of Change:
Mailing Address:
City: / State: / Zip: / Work Phone:

Beginning in September 2012, TriMet is eliminating the distance-based ‘zone’ system of fares, and will sell flat-rate monthly passes instead. Please check the appropriate box:

Adult Pass: $100 (Compares to previous All-Zone @ $92)

Youth Pass: $30 (Compares to previous Youth pass @ $27)

Northwest Regional ESD Authorization
For Monthly Transit Pass Payroll Deduction
I authorize NWRESD deduct from my wages per month until further notice.
I also authorize NWRESD to automatically adjust this amount up to and including the maximum allowed under Federal law to accommodate fare increases.
Print name above
Signature / Date

Revised: 09/04/13
Employee Monthly Transit Pass Payroll Deduction

Northwest Regional Education Service District

DEADLINES

If you need to enroll or cancel
beginning with this pass: / Deadline to submit the change is:
January / December 1
February / January 1
March / February 1
April / March 1
May / April 1
June / May 1
July / June 2
August / July 1
September / August 1
October / September 1
November / October 1
December / November 1

*Please return your completed form to
the Communications Department
at the Regional Office: 503-614-1252*