PAYROLL DEDUCTION AUTHORIZATION FORM

Initial Enrollment Continuation Change
Employer Name
Employee Name Employee Name First Last
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Qualified Transportation Expense (QTE)

Qualified Transportation Expense (QTE) I accept the parking benefit and I elect to have my yearly permit fee paid via payroll deduction on a Pre-Tax Basis. The amount of the pre-tax deduction is subject to yearly adjustments based on changes in the fee structure associated with the campus parking plan. The campus parking plan contains an automatic renewal provision which is aimed at easing the administrative requirements for eligible employees. Because of this provision, I understand payroll deductions will continue until the Payroll Department is notified in writing with a termination request by submitting this form. I agree to return my parking permit should I terminate employment or change status so I am not eligible for the parking benefit. Ialsounderstandthatintheseinstancesfailuretoreturntheparkingpermitwillresultin the revocation of all campus parking privileges associated with the parking permit. I accept the parking benefit and I elect to have m y yearly permit fee paid via payroll deduction, but I waive the Pre-Tax deduction provision. I elect to waive the opportunity to participate in the Pre-tax Parking Plan. I understand by not participating in the plan, any cost I am required to pay for my faculty parking permit will be made after all applicable federal and state taxes have been withheld. Termination of payroll deduction for the Parking Plan I elect to cancel my payroll deduction for the campus parking plan. I understand the deduction will be canceled on the first pay date available for processing payroll adjustments after the date this form is accepted by the Payroll Department. I also understand that by canceling the payroll deduction I am no longer participating in the campus parking plan and I forfeit all parking privileges associated with the permit.
Annual Payroll Deduction Information:

❖ Payroll deductions will be made each period beginning on Sept. 1 and ending on Aug. 31 of each year.
❖ There will be a total of 24 deductions made during the Plan Year.
I understand that by signing and submitting this enrollment form, I am making an election that will remain in effect until a new enrollment form is submitted or when a permissible change has occurred. Moreover, I authorize the payroll deductions indicated above.
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Date Date / MM / DD YYYY

PAYROLL DEDUCTION AUTHORIZATION FORM

PAYROLL DEDUCTION AUTHORIZATION FORM

Annual Payroll Deduction Information:

I understand that by signing and submitting this enrollment form, I am making an election that will remain in effect until a new enrollment form is submitted or when a permissible change has occurred. Moreover, I authorize the payroll deductions indicated above.