Johns Hopkins Hospital System

Commuter Request Form

The IRS allows a maximum of $230 per month to be deducted from your salary on a pre-tax basis for the purchase of monthly MTA passes (to be used on MTA Buses, Light Rail or Metro Subway). The payments are paid through the first paycheck of the purchase of the next month’s pass.

Name(Required)

First Last

Personnel #(Required)

Work Ext(Required)

Request type:(Required)

Enrollment

Change

Termination

Organization:(Required)

Johns Hopkins Health System Corporation

The Johns Hopkins Hospital

Johns Hopkins Community Physicians

Select your pass for the bus, metro subway and light rail:(Required)

Regular – $77

Express – $93

Senior (65+) or Disability – $23

A picture ID is required when using a senior or disability pass.

Please check the box to authorize paycheck deductions. Note: Processing your application may take up to 30 days once received by Human Resources Central Office. Once your application has been processed, you will see the deduction on your paystub.(Required)

I authorize JHHSC/JHH to deduct the above amount from my paycheck. This authorization will remain in effect until I have canceled it in writing, at least 30 days prior to the effective to enroll and/or the cancellation date. I understand that passes are non-transferable. I will pick up my pass at the below location prior to the 9th day of the following month.

Please check the box to authorize termination.(Required)

I authorize JHHS to stop deducting the above amount from my paycheck. This authorization will remain in effect until I submit a request for deductions to resume.

Signature (enter your full name):(Required)

English