TRANSITCHEK® COMMUTER

1 transitchek COMMUTER transitchek Prepaid Visa Card (Not Returnable/Refundable). Employee Enrollment Form The transitchek card can be used to purchase your transit tickets and passes everywhere Visa debit cards are accepted that exclusively sells transit fare media. You can also add funds from a personal credit or debit card for transit passes that exceed the stated value of the Card. To add transitchek is an IRS-approved COMMUTER benefits program that lets funds, go to: you save money by paying for your commute by transit or eligible vanpools with tax-free dollars (see limits below). You are eligible to use Quantity CosVltem Quantity CosVltem $ __ $ __. up to the IRS allowable amount, tax-free. __ x$__ __ x$__. __ x$__ = $ __ __ x$__ $ __.

2 __ x$__ = $ __ __ x$__ $ __. To enroll and begin saving, follow the step-by-step instructions below. Minimum amount $ , Maximum amount $ Return this form to your company's transitchek Program administrator by: _____ transitchek Voucher (Not Returnable/Refundable). Not accepted at MTA NYC Transit subway station booths, Metro-North Railroad, Long Island Rail Road. transitchek Vouchers can be used to purchase your transit tickets and passes. They are accepted by most COMMUTER rail, subway, bus, ferry, and ticket-by-mail programs throughout the country. - How do you commute to work? Check all that apply. D Bus D Vanpool Quantity CosVltem Quantity CosVltem D Subway D Ferry __ x$15 $ __ __ x$50 $ __. __ x$25 $ __ __ x$55 = $ __. D COMMUTER Rail / Light Rail __ x$30 $ __ __ x$75 = $ __.

3 D Other (please specify) _____ __ x$35 $ __ __ x$100= $ __. __ x$45 $ __. How much are you currently paying for your monthly transitchek MetroCard . transit commute? The transitchek MetroCard can be used on MTA-NYC Transit subway, $ _____ I month local and express buses and other MetroCard-equipped services throughout New York City. Pay-Per-Ride Cards (includes 5% bonus). Quantity CosVltem How much of your pay would you like to set aside as a pre-tax $ (1o trips) __ x$ $ ____. payroll deduction towards your commute each month? Please $ (15 trips) __ x$ $ ____. $ (20 trips) __ x$ $ ____. note, there is an IRS monthly limit of $260. $ ____. $ (24 trips) __ x$ $ _____ I month Unlimited Ride Cards 7-Day Unlimited __ x$ $ ____. 7-Day Express Bus Plus __ x$ $ ____.

4 30-Day Unlimited __ x$ $ ____. Use the transitchek Product Selection Chartto the right to choose the product(s) you would like to use for your benefit. Please Access-A-Ride note that if you choose more than one product or select multiple Access-A-Ride provides door-to-door transportation for eligible commuters with denominations of a single product, the total value of all selections disabilities within the five boroughs of New York City. cannot exceed the IRS limit of $260/month. Quantity CosVltem ___ X$ $ ____. Mail&Ride Return this completed form to your transitchek Program administrator. Mail&Ride is a program offered by Metro-North Railroad and Long Island Rail Road transitchek products will be distributed to you at work and will be where you can receive your rail tickets at home instead of purchasing them at a station ready to use.

5 You may not return or get a refund once your benefit window or vending machine. products have been distributed. Long Island Rail Road Account# _____ $ ____. Metro-North Railroad Account# _____ $ ____. Employee name: _____ Name on Account (First) _____ (Last) _____. Date: _____. TOTAL OF ALL PRODUCTS SELECTED (Cannot exceed S260tmonthl $ _____ I month . transitchek . by WageWorks\ /. The transitchek Prepaid Visa card is issued by The Bancorp Bank pursuant to a license from Visa Inc. The Bancorp Bank; Member FDIC. 2017 WageWorks, Inc. All Rights Reserved. GENEEF-1117.)