SF Commuter Benefit Compliance Reporting Form

Business Account Number

(Please submit a separate form for each BAN)

Business Name

Business Street Address (Headquarters)

Address Line 2

City

State

Postal Code

Business Website

Does your company also have a San Francisco address(es)?

NoYes, just 1Yes, more than 1

Please fill out and attach this spreadsheet detailing all the locations covered by this Business Registration Certification.

Nationwide employee count:

San Francisco employee count:

If you have more than 50 full-time employees in the Bay Area, you must register at https://511.org/employers/commuter-benefits-program

How were you notified to fill out the Compliance Reporting Form?
Please select all that apply

Email from the Department of the EnvironmentMailing about the Commuter Benefits and Healthcare OrdinancesBy a colleague at my organizationEmail from my benefits service providerBusiness association or Community Benefit DistrictSocial MediaOther (please describe below)

If other (please describe below)

Our company is:

Currently offering a commuter benefits program

In the process of setting up a commuter benefits program

Needing assistance to set up a commuter benefits program

Not offering a programExempt from the San Francisco OrdinanceOther (please describe below)

Please explain why you are not offering a program

Other (please describe your company's situation)

Which type(s) of commuter benefits program do you offer your employees? Select all that apply.

Pre-tax employee-paid transit/vanpool deductions

Employer-paid subsidy (monthly subsidy for transportation expenses)

Employer-provided shuttle service

Which type(s) of commuter benefits program are you planning to offer your employees? Select all that apply.

Pre-tax employee-paid transit/vanpool deductions

Employer-paid subsidy for transit/vanpool

Employer-paid shuttle service

When do you anticipate the program will be available to your employees? (The Ordinance allows 90 days for you to implement a program)

Do you use a third-party vendor to help you administer your program?

YesNo

What is the name of the vendor?

Other vendor:

As of today, how many San Francisco employees are participating in your commuter benefits program?

Did you start your commuter benefits program because of the Commuter Benefits Ordinance requirements?

YesNo

Is your commuter benefits program offered to employees:

Company-WideJust in San Francisco

Would you like to schedule a consultation with CommuteSmart?

YesNo

Type of consultation

In personPhone

Which days are you generally available?

Which times are you generally available? Check all that apply

MorningAfternoon

Reason for exemption (select all that apply):

(please note SF Environment may follow up with you to verify your exempt status)

We have fewer than 20 employees nationwideWe are a State/Federal entityWe do not have a business location in San FranciscoAll San Francisco employees telecommuteWe are a construction/contractor company with a project less than 6 months duration in San FranciscoAll employees in San Francisco drive company vehiclesWe are reporting through the Bay Area Commuter Benefits ProgramOther

If Other was selected, please explain:

Are you offering Commuter Benefits even though you are exempt from the Ordinance?

YesNo

Do you offer any other transportation incentives to your employees? Please select all that apply.

Other (please describe below):

What percent of employees in your San Francisco office(s) are provided free parking or parking subsidies?

For these employees, what is the average subsidy amount per month?

Parking cash out is defined as offering cash in exchange for choosing not to have parking spaces. Is this the option you give employees who are eligible for a parking subsidy?

YesNo

How many employees do you offer parking cash-out to?

How many employees choose the cash-out and receive the payment instead of a parking spaces?

Commuter Benefits Confirmation:

By checking this box, I certify that the information on this Compliance Reporting Form is accurate and true to the best of my knowledge.

Today's Date