Benefit Card Delivery Fee Waiver Request Form

Benefit Card Delivery Fee Waiver Request Form
Submit your request to waive the delivery fee for your benefit card. Please complete all required fields to ensure proper evaluation.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Benefit Card
Reason for Waiver Request
Are you currently receiving any government assistance?
Have you previously received a delivery fee waiver for this card?
Upload any supporting documentation (if applicable)
Cancelof
Additional Information or Comments
Should be Empty: