Mandatory Reference: 515 File Name: 515maa 071802 cd28 united states




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Mandatory Reference: 515


File Name: 515maa_071802_cd28

UNITED STATES


AGENCY FOR INTERNATIONAL DEVELOPMENT

APPLICATION FOR TRANSIT BENEFIT


(Check One)

 Direct Hire


 Personal Services Contractor


 Change of Address

PLEASE COMPLETE FORM AND TYPE OR PRINT LEGIBLY

  1. Last Name:
         

  1. First Name:
         

  1. Last four digits SSN:
        

  1. Home Address (Number/Street):
         

  1. City:
         

  1. State:
      

  1. Zip Code:
         

  1. Bureau
         

  1. Room Number:
         

  1. Telephone (Work):
    (   )-   -    

  1. Commuting method to/and from work:




 METRO RAIL

 TRANSIT AUTHORITY VANPOOL




 BUS

 VRE TRAIN




 MARC TRAIN

 OTHER (EXPLAIN)




  1. Are you currently in a carpool with USAID or any other government agency?




 NO

 YES (IF YES, PRIMARY DRIVER’S NAME)     




  1. Which Metro station is nearest to your home?      

EMPLOYEE CERTIFICATION


YES

NO








I certify that I am employed by the United States Agency for International Development, and am not named on a Federal-subsidized workplace parking permit with USAID or any other Federal Agency.





I certify that I am eligible for a public transportation fare benefit, will use it for my daily commute to and from work and will not transfer it to anyone else.





I certify that my monthly transit benefit I am receiving does not exceed my monthly commuting costs.





I certify that my actual monthly commuting cost are      





I certify that I am an employee of another Federal agency; that my principal workplace is in the RRB; and I am not receiving a public transportation fare benefit from my parent agency.

This certificate concerns a matter within the jurisdiction of an agency of the United States Government. Making a false, fictitious, fraudulent certification may subject you to prosecution under Title 18, United States Code, Section 1001; or Civil Penalty Action, providing for administrative recoveries of up to $5,000 per violation; and/or agency disciplinary actions up to and including dismissal.

EMPLOYEE SIGNATURE:




DATE:      

14. AMS OFFICER SIGNATURE:     

PROGRAM MANAGER SIGNATURE, M/AS/CPD:

AMOUNT APPROVED $     




DATE PROCESSED:     

AID 515-1 (12/2001)


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