Pretax Transit and Parking Enrollment

Public Transit -- Off Campus Parking Providers


Enrollment Action:
General

Payment Method
I authorize HR Simplified, Inc. to initiate credit entries and, if necessary, to initiate any debit entries to correct an erroneous credit entry to my account at the DEPOSITORY (identified below), for the purpose of automatically depositing funds to my account. I acknowledge that the origination of these transactions must comply with the provisions of U.S. Law. I understand that my first reimbursement may be in the form of a check, while electronic reimbursement is being established.
Depository Name (Bank)* City* State* Zip* Branch Phone
Routing Number* Account Number* Account Type*

PRE-TAX - My Monthly Election Amount
$$
Monthly Maximum Election $255.00
Monthly Maximum Election $255.00

POST-TAX - My Monthly Election Amount - Tell me more...
$$
Requires Transit Pre-Tax ElectionRequires Parking Pre-Tax Election


Requested Effective Date* :

Your request must be submitted by the 1st of the month prior to your Requested Effective Date
Example 1: If my requested effective date is June 1st, I must request this change no later than May 1
Example 2: If my request to change is submitted on May 2nd, then your effective date will be July 1

  I understand that this authorization replaces any previous authorization and will remain in full force and effect until HR Simplified, Inc. has received written notification from me of its termination in such time and in such manner as to afford the HR Simplified, Inc. and the DEPOSITORY a reasonable opportunity to act on it.



PRIVACY NOTIFICATION
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply information about themselves. The principal purpose for requesting the information on this form is for administrative record keeping and for purposes of payment. Furnishing all information requested on this form is mandatory --failure to provide such information may delay your Pretax Transit Pass enrollment. Information furnished on this form may be used by the University payroll office for payroll deduction purposes. Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements. Information on applicable policies and agreements can be obtained from campus or Office of the President Staff and Academic Personnel Offices. The official department responsible for maintaining the information contained on this form is Transportation Services. (PTS vers.3.02)