Outstanding Balance Repayment Form

Instructions

Please fill out your details below and mail this form, along with a check for your total balance due, to:

Alight Smart-Choice Accounts P.O. Box 660114

Dallas, TX 75266-0114

Your Details

Employer Name:

First Name:

Last Name:

Mailing Address:

Employee ID or Last 4 of SSN:

Please note: It may take up to 5 business days to process your repayment once it is received.