EXAMPLE OF INITIAL TASK ORDER REQUEST

Account # Request Date 

5555555 02/15/21 

PO # DUE DATE

03/15/2021 

Terms

Net 30

AMOUNT DUE:

$29,240.00 

Description Participants Service 

Months

Rate Amount

HC FSA Accounts with January 

Effective Date

1,000 12 2.00 24,000.00

DC FSA Accounts with January 

Effective Date

200 12 2.00 4,800.00

HC FSA Accounts with February 

Effective Date

10 11 2.00 220.00

DC FSA Accounts with February

Effective Date

10 11 2.00 220.00

Administrative Fee Total Amount required for Task Order $29,240.00

Risk Reserve Total 1,010 12 .25 $3,030.00

To: Agency Name

Street Address

City, State Zip

Remit: The Task Order should be submitted by March 15th, 2021 to 

FSAFEDSBilling@healthequity.com and InternetFSA@opm.gov

Admin Fee Acct #: 121000248 Routing, 4122286842

For Task Order Request inquiries, please contact your HealthEquity 

AR Representative at (480) 804-2335 or email 

FSAFEDSBilling@healthequity.com. 

HealthEquity, Inc.

Attn: Shared Services/Collections

4609 Regent Blvd. #100

Irving, TX 75063

Tax ID: 52-2383166 

DUNS: 793506390 

CC: 8L0Q7

Contract#: 24361820D0002

TASK ORDER REQUEST

Re: FSAFEDS – 2021 Task Order Request, Due March 15, 2021

We are providing you with your agency’s FSAFEDS administrative and 

reserve account fees for the 2021 calendar year based on open season

activity. You will receive your detailed employee reports that supports

this request separately. Please submit your fully executed Task Order for 

the full calendar year amount of the administrative fees via email to 

FSAFEDSBilling@healthequity.com and InternetFSA@opm.gov no later

than March 15th, 2021.

NOTE: The Risk Reserve amount should not be included in the Task Order funding. The Risk Reserve portion is based upon the 

number of Health Care and Limited Expense accounts. Also, the Risk Reserve will be invoiced separately on the same quarterly 

schedule as the regular invoices. 
EXAMPLE OF QUARTERLY INVOICE

Account # Invoice Date

5555555 04/01/2021 

PO # DUE DATE

1234567890 05/01/2021 

Invoice # Terms

INV1234567 Net 30

AMOUNT DUE:

$1,880.00 

Description Participants Service 

Months

Rate Amount

HC FSA Accounts with January 

Effective Date

250 3 2.00 1,500.00

DC FSA Accounts with January 

Effective Date

50 3 2.00 300.00

HC FSA Accounts with February 

Effective Date

10 2 2.00 40.00

DC FSA Accounts with February

Effective Date

10 2 2.00 40.00

To: Agency Name

Street Address

City, State Zip

Remit: Remit: Via Wire or ACH to Wells Fargo, N.A.

Admin Fee Acct #: 121000248 Routing, 4122286842

Please include Customer # and Invoice # in your payment addenda.

For Invoice and Banking information inquiries, please contact your 

HealthEquity AR Representative at (480) 804-2335 or email 

FSAFEDSBilling@healthequity.com. 

HealthEquity, Inc.

Attn: Shared Services/Collections

4609 Regent Blvd. #100

Irving, TX 75063

Tax ID: 52-2383166 

DUNS: 793506390 

CC: 8L0Q7

Contract#: 24361820D0002

INVOICE

Total Amount Due: $1,880.00

Re: FSAFEDS 2021 Quarterly Invoice Payment is due within 30 days of receipt.
Account # Request Date 

5555555 11/01/21 

PO # DUE DATE

12/01/21 

Terms

Net 30

AMOUNT DUE:

$30,950.00 

Description Participants Service 

Months

Rate Amount

HC FSA Accounts with March 

Effective Date

50 10 2.00 1,000.00

DC FSA Accounts with March 

Effective Date

25 10 2.00 500.00

HC FSA Accounts with June Effective 

Date

10 7 2.00 140.00

DC FSA Accounts with June Effective 

Date

5 7 2.00 70.00

ORIGINAL Task Order Total $29,240.00

CATCH-UP Task Order Total $1,710.00

UPDATED Task Order Total $30,950.00

Risk Reserve March 50 10 .25 125.00

Risk Reserve June 10 7 .25 17.50

Risk Reserve Total 142.50

To: Agency Name

Street Address

City, State Zip

Remit: The Task Order should be submitted by December 1st, 2021 to 

FSAFEDSBilling@healthequity.com and InternetFSA@opm.gov

Admin Fee Acct #: 121000248 Routing, 4122286842

For Task Order Request inquiries, please contact your HealthEquity 

AR Representative at (480) 804-2335 or email 

FSAFEDSBilling@healthequity.com. 

HealthEquity, Inc.

Attn: Shared Services/Collections

4609 Regent Blvd. #100

Irving, TX 75063

Tax ID: 52-2383166 

DUNS: 793506390 

CC: 8L0Q7

Contract#: 24361820D0002

CATCH-UP TASK ORDER REQUEST

Re: FSAFEDS – 2021 Task Order Update Required, Due December 1st, 2021

We are providing you with your agency’s FSAFEDS administrative and 

reserve account fees for new accounts established after open season. The 

original task order must be updated to reflect the additional accounts. You

will receive your detailed employee reports that supports this invoice

separately. Please submit your fully updated and executed Task Order for 

the full calendar year amount of the administrative fees via email to 

FSAFEDSBilling@healthequity.com and InternetFSA@opm.gov no later

than December 1st, 2021.

NOTE: The Risk Reserve amount should not be included in the Task Order funding. The Risk Reserve portion is based upon the 

number of Health Care and Limited Expense accounts. Also, the Risk Reserve will be invoiced separately on the same quarterly 

schedule as the regular invoices. 

EXAMPLE OF CATCH-UP TASK ORDER REQUEST FOR NEW ACCOUNTS POST OPEN SEASON
Account # Invoice Date

5555555 01/31/2022 

PO # DUE DATE

1234567890 01/31/2022 

Invoice # Terms

INV1234567 Net 30

AMOUNT DUE:

$1,710.00 

Description Participants Service 

Months

Rate Amount

HC FSA Accounts with March 

Effective Date

50 10 2.00 1,000.00

DC FSA Accounts with March 

Effective Date

25 10 2.00 500.00

HC FSA Accounts with June Effective 

Date

10 7 2.00 140.00

DC FSA Accounts with June Effective 

Date

5 7 2.00 70.00

Administrative Fee Total $1,710.00

To: Agency Name

Street Address

City, State Zip

Remit: Via Wire or ACH to Wells Fargo, N.A.

Admin Fee Acct #: 121000248 Routing, 4122286842

Please include Customer # and Invoice # in your payment addenda.

For Invoice and Banking information inquiries, please contact your 

HealthEquity AR Representative at (480) 804-2335 or email 

FSAFEDSBilling@healthequity.com. 

HealthEquity, Inc.

Attn: Shared Services/Collections

4609 Regent Blvd. #100

Irving, TX 75063

Tax ID: 52-2383166 

DUNS: 793506390 

CC: 8L0Q7

Contract#: 24361820D0002

 INVOICE

Total Amount Due: $1,710.00

Re: FSAFEDS 2021 Invoice Payment is due within 30 days of receipt.

EXAMPLE OF CATCH-UP INVOICE TO BE SENT IN JANUARY 2022