TransitChek CashBack® Commuter Parking
Reimbursement Form
SECTION I : FILL OUT ALL THE INFORMATION BELOW
Date: ____________________ Employer: ___________________________________________________
Name: _____________________ ___________________ _____ Employee #: ____________________
Last
First
MI
Address: ______________________________________________________________________________
Street / P.O. Box
____________________________
City
__________
State
___________________
Zip Code
Home Telephone: ( _____ ) _________________
SECTION II : FILL OUT ALL THE INFORMATION BELOW
Parking Lot / Station
Name & Address
Benefit Month
Monthly Expense
Amount
Receipts Attached?
(Y or N)
$
$
$
NOTICE: Please submit your claims as soon as possible after the service(s) you are claiming
reimbursement for have been rendered. Based on IRS guidelines, claims submitted more than 180 days
after the period for which the expense was incurred will be denied. For customer service, please call
1.888.618.CHEK (2435)
CLAIM CERTIFICATION: I hereby certify that I have incurred the foregoing expenses for the month(s) indicated
to pay for parking on or near my employer’s business premises or on or near a location from which I commute to
work by mass transit, vanpool or carpool. I understand that requests for reimbursement are subject to the
®
TransitChek Premium Program Terms and Conditions which I have agreed to in order to participate in this
program. Claims submitted which are not in accordance with the Terms and Conditions are prohibited and may
subject me to penalties including loss of my benefits. For information on the TransitChek Premium Program or to
review the Terms and Conditions, please log onto www.TransitChek.com.
____________________________________________
Signature (REQUIRED)
______________________
Date
NO RECEIPT CERTIFICATION: I hereby certify that the parking location only accepts CASH and does not
provide any form of receipt.
____________________________________________
Signature
______________________
Date
(See attached page of the INSTRUCTIONS FOR SUBMITTING A TRANSITCHEK CASHBACK REIMBURSEMENT)
®
TransitChek is a registered trademark of WageWorks, Inc.
Copyright ©2017 WageWorks, Inc. All rights reserved.
TCP_0317
INSTRUCTIONS FOR SUBMITTING A TRANSITCHEK CASHBACK® REIMBURSEMENT - PARKING
SECTION I.
Please fill out all the information requested.
SECTION II.
For each location you pay to park, enter the name and address of the commuter parking lot or other parking
facility. If you park at a transit location, please provide the name of the service, the line and the name of the
station or other parking facility, as appropriate. For each location, provide the total expense you incurred in
each month separately.
You must sign and date the CLAIM CERTIFICATION and, if the parking facility does not offer receipts, the NO
RECEIPT CERTIFICATION to complete your claim. Please attach your receipts to this Form and keep a copy
of your receipts in case your claim is lost in the mail or for future reference.
Submit your completed TransitChek CashBack Reimbursement Form to:
EMAIL
FAX
[email protected]
855.568.9501
MAIL
TransitChek
36 W 44th Street
Suite 1202
New York, NY 10036
®
TransitChek is a registered trademark of WageWorks, Inc.
Copyright ©2017 WageWorks, Inc. All rights reserved.
TCP_0317