TransitChek CashBack Transit Reimbursement Form

1 SECTION I : FILL OUT ALL THE INFORMATION BELOWSECTION II : FILL OUT ALL THE INFORMATION BELOWT ransitC hek CashBack TransitReimbursement FormDate :_____Employer:_____Name:_____ _____ _____ Employee # :_____Last Firs t MI Address: _____ St re et / Box _____ _ _____ City State Zip Code Home Telephone:( _____ ) _____ Transit OperatorBenefi t MonthMonthly ExpenseReceipts Attached?Amount(Y or N) (See attached page of the INSTRUCTIONS FOR SUBMITTING A TransitChek CashBack Reimbursement ) $ $ $ CLAIM CERTIFICATION: I hereby cert ify that I have incurred the fore going expenses for t he month(s) indicated to pay for tra nsit expenses. I understand that requests for re imbursement are subject to the TransitChek Premium Progra m Terms and Conditions which I have agre ed to in ord er t o participate in this program.

2 Claims submitted which are not in accordance with the Terms and Conditions are pro hibited and may subject me to penalties including loss of my benefits. For information on the TransitChek Pr emium Pr ogram or to re view the Terms and Conditions, please log onto gnature(REQUIRED)DateNO RECEI PT CERTIFICATION: I hereby cert ify that the Transit operatoronly accepts CASHand does not pro vide any form of re ceipt. _____Si gnatureDateNOTICE:Please submit y our claims as s oon as possibl e af ter the ser vice( s) y ou are claiming rei mbursement for have been rendered. Bas ed on IR S g ui delines, claims s ubmitted mor e than 180 daysaf ter the period for w hi ch the expense was i ncurredwill be denied. For c us tomer s er vice, pl ease call (2435) TransitChek is a registered trademark of WageWorks, 2017 WageWorks, Inc. All rights reser ved. TCP_0317 IN STRUCTIO NS F OR SUBMITTING A T RANSIT CHEK CashBack Reimbursement - TRANSITSECTIO N I.

3 Please fill out all the infor mati on requested. SECTIO N II. For each tr ansit operator, enter the name of the Transit oper ator. For each Transit operator, prov ide the total ex pense you inc urred in each month mus t sign and date the CLAIM C ERTIFIC ATION and, if the Transit operator does not offer r ec ei pts, the NO R ECEIP T C ERTIFIC ATION to compl ete your c lai m. Please attach your r ec ei pts t o this F or m and keep a copy of y our r ec ei pts i n case y our claim i s l os t in the mail or f or f uture ref er y our c ompl eted TransitChek C as hBack R ei mbursement form to: MAILT ransitChek36 W 44th StreetSuite 1202 New York, NY is a registered trademark of WageWorks, 2017 WageWorks, Inc. All rights reser ved. TCP_0317