| Name:______________________________________ | Social Security Number*:_______________________ |
| Department:__________________________________ | Campus Mailbox:_________________ |
| Phone:__________________ | |
| 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. | |
| Employee Signature:___________________________ | Date:________________ |
| Benefits & Work/Life Office, Box 355660 |
|
| *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:___________________________ |