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Copyright ©2018
TRANSIT CASH OUT REQUEST FORM
Please complete and sign this form in its entirety if you were unable to use your Benefits Card to secure your transit pass.
1. Submit the completed form to Igoe Administrative Services for review via: • Email to [email protected] • Fax to 800-456-9083 Please make sure to properly dial the fax number listed on this form. Igoe accepts no
responsibility for transmissions that are routed to the wrong location based on dialer error. 2. Please allow up to 4 business days for claim review and reimbursement notification. 3. Questions? Please contact Participant Services at [email protected], 1-800-633-8818, Opt# 1.
Basic Employee Information 1. Employer Name: 2. Employee Name: 3. Address: 4. Email Address:
Choose the Reason for your Cash Out Request I do not have my Benefits Card for one of the following reasons:
• I am a new enrollee and the Benefits Card has not been delivered. • I lost my Benefits Card.
The merchant was unable to use my Benefits Card for one of the following reasons: • The card terminal was experiencing technical issues. • The Benefit Card declined at the point of sale. • Benefit Cards are not accepted at the merchant location.
I am no longer a participant in the Commuter Program and am requesting a refund of any post-tax contributions currently in my account.
Please provide details regarding the Transit purchase and claim amount This date will be used to determine when the pass or voucher is effective. For example, a pass purchased in January will apply toward January transportation activity and eligible claim amount.
Purchase Date:
Purchase Amount:
Signature/Attestation By signing, I attest that I understand the rules of the Commuter Benefit Program as defined under IRS §132, specifically the Cash Reimbursements – Special Rule. The Rule allows for cash reimbursement on a nontaxable basis only if no voucher or similar item is readily available for direct distribution. I understand that a request to receive cash can only be approved if use of a Benefits Card was not available to me based on the above listed reasons. I attest that the information provided here is truthful.
Print Name:
Signature: _________________________________
Date:
