DOI Recertification Instructions and Enrollment Master Spreadsheet National Capital Region REV by hn6D35bR

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									INSTRUCTIONS FOR COMPLETING THE APPLICATION SUBMISSION FORMS:

1. This file contains three tabs/worksheets, for New Enrollment,
Withdrawal, and Change Request. Application forms are to be separated into
these categories and entered into the appropriate worksheet in the file.

2. Please DO NOT alter the format of the spreadsheet. Do not insert columns or
change column widths. If you "freeze" rows or columns (e.g. the column titles)
please "unfreeze" them before you save the file to send.

3. Complete the spreadsheet electronically. Do not fill it out manually. Complete
all applicable columns. Carefully check the information entered for accuracy.
This will allow DOT to “cut and paste” required information and reduce the chances
of typing errors. Incomplete submissions will be returned to the sender for correction.

4. Fill in the POC information at the top of each worksheet with your own information.
Enter the date the file is sent to DOT.

5. The "Total" cell on each page contains a formula which adds all the completed
lines. Do not type in this cell or change the formula.

6. On the “Withdrawal” worksheet, enter a brief description of the reason for
withdrawal, e.g. “Retiring”, “Suspension”, “Leaving Agency", "Parking”.

7. On the “Change Request” worksheet, enter a brief description of the change
request, e.g. “Name change”, ”Commuting cost change”. Note that only name
changes, change in type of fare media requested, or changes to the amount
requested need to be entered in this worksheet for submission to DOT. Other
changes, such as residence information, etc. do not need to be
sent to DOT, but will be kept on file by the DOI POC

8. Send the completed Submission forms file in its original Excel format via email
to the DOT DC Account Manager. The deadline for new application is the 25th of each month. Please
DO NOT change the file type (e.g. do not send it as a .pdf file).

9. Applications will be processed during the month after the file is received by DOT,
and benefit will be available to the applicant to begin the following month (e.g.,
applications received between the 1st of the month – the 25th of the month will be processed the Smart B
and Debit cards will be effective the following month.

10. Only one monthly submission from each location will be accepted for action.

11. Only the Submission forms file is to be sent to . DO NOT send individual
application forms or “Commuter Expenses Calculation Worksheets”. Each Point of Contact
will keep the application forms and calculation worksheets on file.

12. Please indicate if participant is New or Re-Enrollment
ch month. Please




rocessed the Smart Benefit changes
                                                                                                   Department of
                                                                                    MASS TRANSPORTATION BENEFIT PROGRAM
                                                                                 NATIONAL CAPTIAL REGION AND REGIONAL OFFICES
                                                                                       NEW ENROLLMENT SUBMISSION FORM
                                                                                        This form is for new applicants only.
SUBMISSION DATE:


Bureau POC NAME:
Bureau POC PHONE:
Bureau POC EMAIL:

BUILDING ADDRESS
(INCLUDING RM OR STE #):
LOCATION (CITY, STATE & ZIP CODE):                                                                                                                                                                                                                CARD NOT REGISTERED
                                                                                                                                                                                                                                                  PARTICIPANT NEEDS OWN CARD
Total Enrolling:                        0-Jan-00                                                                                                                                                                                                  NEEDS NEW CARD
                                                                                                                                                                                                                                                  READY TO GO
                                                              RESIDENCE                                                                                   DAT E                                                                       DATE        REQUIRED TO WITHDRAW FOR OLD AGENCY
                                     New & Re-     LAST 4   CITY &STATE,                     MODE OF      MONTHLY AMOUNT    SMART TRIP   ACCOUNTING   RET URNED                                      Local POC                        BENEFIT     PARTICIPANT HAS RECEIVED BENEFIT
    LAST NAME             FIRST NAME Enrollment     SSN     INCLUDING ZIP   W ORK PHONE   TRANSPORATION      CERTIFIED     CARD NUMBER      CODE      T O POC FOR   ACTION REQUESTED   Local POC   Phone Number   Local POC Address   AVAILABLE
                                                                                  DEPARTMENT
                                                                MASS TRANSPORTATION BENEFIT PROGRAM
                                                            NATIONAL CAPTIAL REGION AND REGIONAL OFFICES
                                                                  WITHDRAWAL SUBMISSION FORM
                                                            This form is for w ithdraw ing participants only.
SUBMISSION DATE:


Bureau POC NAME:
Bureau POC PHONE:
Bureau POC EMAIL:
BUILDING ADDRESS (INCLUDING RM
OR STE #):
LOCATION (CITY, STATE & ZIP CODE):



Total Withdrawing:                    ##

                                                                      MONTHLY                                   Local POC
                                           LAST 4     FARE MEDIA       AMOUNT      SMART TRIP                     Phone     Local POC
  LAST NAME              FIRST NAME   MI    SSN       REQUESTED       CERTIFIED   CARD NUMBER    Local POC       Number      Address    Reason for W ithdrawal

                                                                                                                                                                 PARKING
Wayne               Bruce             B    ########    BUS PASS         $230.00                                                                                  NO LONGER WITH AGENCY

Parker              Peter             S    ########    TRANBEN          $86.00                                                                                   RETIRING

                                                                                                                                                                 CUSTOMER REQUEST
                                                                                                                                                                 POC REQUEST
                                                                               DEPARTMENT OF
                                                                MASS TRANSPORTATION BENEFIT PROGRAM
                                                                          NATIONAL CAPTIAL REGION
                                                                    CHANGE REQEST SUBMISSION FORM
                                                        This form is for participants w ho are making a change to their information only.
SUBMISSION DATE:


Bureau POC NAME:
Bureau POC PHONE:
Bureau POC EMAIL:
BUILDING ADDRESS (INCLUDING RM
OR STE #):
LOCATION (CITY, STATE & ZIP CODE):

                                                                                                                                                                                                                                   Drop Down List
Total Change Requests:                 ##
                                                                                                                                                                                                                                   CARD NOT REGISTERED
                                                                                        MONTHLY                                                                                                                                    PARTICIPANT NEEDS OWN CARD
                                                        RESIDENCE CITY,   W ork phone                SMART TRIP CARD                         ACTION REQUESTED                                                                      NEEDS NEW CARD
                                                                                         AMOUNT                                                                    MODE OF                   Local POC Phone
   LAST NAME              FIRST NAME   MI   Last Four   STATE, ZIP CODE     Number      CERTIFIED       NUMBER             ACCOUNTING CODE                      TRANSPORTATION   Local POC       Number        Local POC Address   READY TO GO

                                                                                                                                                                                                                                   REQUIRED TO WITHDRAW FOR OLD AGENCY

                                                                                                                                                                                                                                   PARTICIPANT HAS RECEIVED BENEFIT
                                                                                                                                                                                                                                   SEND
                                                                                                                                                                                                                                   APPLICAT ION NOT

								
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