Skip to main content

Forms

Down Payment Assistance Form

Down Payment request form.

FSA Nutrition Card Now Accepted at Walmart

FSA TPA is pleased to welcome Walmart as its latest merchant to its expansive Nationwide EBT network of retailers. The FSA Nutrition card is a valuable tool for Tribal Nations looking to provide Nutrition benefits to their Tribal citizens in a secure and convenient manner. Click the PDF download to read the Press Release and learn more about the FSA Nutrition Card.

FSA TPA Claim Reimbursement Form

Form for reimbursable expenses under the Tribal Member Benefits Program.

FSA TPA Direct Deposit Authorization Form

Authorize your claim reimbursement by direct deposit into a checking or savings account.

FSA TPA Flexible Spending Account Reimbursement Request Form

Utilize the FSA Reimbursement account request form to request reimbursements from either your healthcare or dependent care flexible spending account provided by your Employer.

FSA TPA Provider Payment Authorization Form

Utilize provider payments for any fixed payment amount to eligible mortgage, rental, education, or other providers deemed eligible by the Program.

Looking to learn more? Contact Us