Individually Billed Card Account Reinstatement Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I: Reinstatement Request Details. Indicate if a replacement card is needed and select the delivery timeframe—standard or expedited.
3. Move to Section II: Cardholder Information. Fill in required fields such as Cardholder Name, Date of Birth, SSN, and Employee ID. Ensure accuracy for timely processing.
4. Provide your Primary Address and, if necessary, complete the Home/Physical Address section if using a P.O. Box.
5. In Section III: Agency Program Coordinator Information, enter the Central Account Number and complete the hierarchy levels as required by your organization.
6. Finally, ensure all signatures are obtained from both the applicant and supervisor before submitting the form through our platform.

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