University of Washington
Pre-Tax Transportation Plan
Waiver Form

Name:______________________________________ Social Security Number*:_______________________
Department:__________________________________ Campus Mailbox:_________________
I elect to waive the opportunity to participate in the University of Washington Pre-tax Transportation Plan. I understand that by waiving participation any premium, I may be required to pay for the transportation option I have selected will be deducted from my paycheck after all federal and/or state taxes have been collected. Further, I understand that I will not be able to change this election until the next annual open enrollment period (typically held in November) for changes effective January 1.
Employee Signature:___________________________ Date:________________
Return with UPass Application, or Payroll Deduction/Termination Agreement, or send to :
UW Benefits Office, Box 359556
*Privacy Act Statement: Your social security number is required on this form to ensure correct tax reporting.
For Benefits/Transportation Office Use Only:
Effective Date:__________________________ Entered:___________________________