2012 CITY AND COUNTY OF
Department: DIA Employee ID #:
Pass Begin Date:
(Must be received by the first of the month to ensure a pass for the following month)
ValuPass selection and associated employee monthly cost (after City subsidy):
The ValuPass is a series of 12 monthly passes, which are purchased by the City and County of Denver (City) in
advance, to participate in the plan you must enroll for 12 months.
The City currently pays seventy-five percent (75%) of the cost of each pass.
Because all 12 passes are purchased in advance by the City, you are responsible for paying the remaining total
cost (employee contribution plus City subsidy) of the ValuPass if you separate from service with the City for any
reason prior to the end of the 12-month period at the unsubsidized monthly rate.
You may purchase the ValuPass anytime for a 12 month period.
You must enroll by the first (1 ) of the month in order to receive your monthly pass in the mail from RTD by
the 1st of the following month (except for January, 2012 renewals, forms must be received by November 23, 2011).
For City Employees only
The pass is non-transferable and non-refundable and may only be utilized by you.
DIA will be auditing this program periodically to ensure pass is being utilized by City employee exclusively. If
you transferred to someone else, you will be charged the full, unsubsidized cost of the pass plus permanent
loss of rights to this program.
I hereby authorize the City and County of Denver to make monthly pre-tax deductions from any compensation or
monies due to me. The monies deducted will be applied to the purchase of the ValuPass indicated above. I
understand by signing this form, the pass will not be transferred to another person, if the pass is
transferred; I will be responsible for the full, unsubsidized cost of the pass.
Employee Signature: Date: / /
By signing this form, I attest that I have read and understand the above rules of RTD’s ValuPass program .
Please return completed form to CSA Benefits at email@example.com, fax to 720-913-5548 or bring it to the
HR Services office in the AOB, 6 Floor.