Model Form for Short Form Disclosures for Government Benefit Accounts

You have several options to receive your payments: direct deposit to your bank account; direct deposit to your own prepaid account; or this benefits card. Tell the benefits office which option you choose.

Type of fee Amount
ATM balance inquiry (in-network or out-of-network) $0 or $1.95*
Customer service (automated or live agent) $0 or $1.95 per call
Inactivity $0
We charge 4 other types of fees. Here are some of them:
Type of fee Amount
[Additional fee type] $0.50 or $1.00
[Additional fee type] $3.00

* This fee can be lower depending on how and where this card is used.
[See [location] for free ways to access your funds and balance information.]

No overdraft/credit feature.
Your funds are eligible for FDIC insurance.

For general information about prepaid accounts, visit
Find details and conditions for all fees and services in the cardholder agreement.