This form is for reimbursement of any out-of-pocket expenses where your Twic Benefits Card was not used, and you do not have a detailed itemized receipt. You may use this for documentation for expenses paid with your Twic Benefits Card for substantiation. Please submit this form with your supporting documents, such as an email invoice or bank statements as proof of the payment via

Should you have any questions, please contact our member experience team via Live Chat, email to, or call us at 844-902-2902

FSA/HSA Reimbursement Form Download Link HERE.

DCFSA Reimbursement Form/Receipt Download Link HERE.

Did this answer your question?