Form H1172
Instructions

EBT Card, PIN
and Data Entry Request

10-2014

PURPOSE

  • To provide a method for the advisor to request that Electronic Benefit Transfer (EBT) issuance staff:
    • issue an initial Lone Star Card or personal identification number (PIN) packet in the office or by mail,
    • enable a cardholder to self-select a PIN, and
    • enter the personal account number (PAN) and PIN control number data.
  • To provide a method for the advisor to request that EBT issuance staff determine if a previously issued Lone Star Card currently held by an individual can be used to access benefits on the specified accounts as identified by the corresponding Eligibility Determination Group (EDG) numbers.
  • To provide a method for the advisor to:
    • notify EBT issuance staff that a particular Lone Star Card or PIN packet has been delivered to a cardholder, and
    • request that EBT issuance staff enter the PAN and PIN control number data.
  • To provide EBT issuance staff with information needed to:
    • locate the primary cardholder record through inquiry into the Administrative Terminal Application (ATA), and
    • enter the PAN and/or PIN control number data.

PROCEDURE

When to Prepare

When an individual becomes a new primary cardholder for a Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) EDG and needs (or upon certification will need) access to the cash or food account.

Number of Copies

The advisor completes an original for each primary cardholder who needs validation or issuance of a Lone Star Card.

Transmittal

The advisor gives the original to EBT issuance staff.

Form Retention

EBT issuance staff retain the signed original in a secure environment for a period of three years.

Records are approved for destruction through the Web-based System of Organized Automated Records (SOAR). Access the site with the following link:

http://hhsc-online.hhsc.state.tx.us/AdminOps/Ops/RM/RecordsMgmt.html

For more information on the purging and destruction of records, refer to the Operational Handbook, Part J, Section 3000, Purge of Obsolete and Inactive Records, and Section 6000, Records Destruction:

http://dadsview.dads.state.tx.us/handbooks/oh/J/index.htm

DETAILED INSTRUCTIONS

Name of Primary Cardholder — Enter the name of the primary cardholder exactly as it is spelled in the Texas Integrated Eligibility Redesign System (TIERS).

TANF and SNAP EDG Numbers — Enter the TANF or SNAP EDG number for which the card/PIN packet is being issued or for which a PIN is being self-selected by the cardholder. If the card/PIN is for both a TANF and SNAP EDG, enter both EDG numbers.

Part I. Request for Issuance/PIN Self-Selection The advisor completes Part I to request that EBT issuance staff issue a card to an individual in the office or by mail. The advisor also indicates whether to enable a cardholder to self-select a PIN or to send a PIN packet to the individual.

Name of Person to Receive Card Enter the name of the person to whom the card must be given or mailed.

Date/Time Enter the date and time of the request.

Action Requested

Issue Card — Check this box if a card needs to be issued to an individual in the office.

Validate Card Check this box if a primary cardholder has a previously issued card and EBT issuance staff must determine if it can be used to access benefits for the EDGs indicated at the top of the form.

Enable Cardholder-Selected PIN Check this box if a cardholder is able to self-select a PIN.

Issue PIN Packet Check this box if a PIN needs to be given to a primary cardholder in the office.

Mail Card/Training Material Check this box if a card and training material need to be mailed to a primary cardholder at the address listed on the primary cardholder record.

Mail PIN Packet Check this box if a PIN packet needs to be mailed to a primary cardholder at the address listed on the primary cardholder record.

Card Registration Required Check this box if the card is to be:

  • given to someone other than the primary cardholder, or
  • mailed.

Cards do not need to be registered if they are issued directly to the primary cardholder.

If TANF Protective Payee — Mailing Address Enter this address if a card or PIN packet must be mailed to a TANF protective payee.

How was the cardholder’s identity verified when the card was issued in the local office? — Describe how the cardholder's identity was verified when the card was issued in the local office. Note: When the card is issued to the primary cardholder in the local office and identity is verified by a Texas driver's license, military identification (ID), or other ID card, enter the ID card number.

Additional training requested? — If the cardholder appears to need further EBT training after the interview or requests further training, check Yes. Otherwise, check No.

If issuing or mailing a PIN packet, indicate the barrier to PIN self-selection: The advisor or clerk who identifies the client's barrier to PIN self-selection completes this section by indicating the type of barrier.

Part II. Notification of Issuance The advisor completes Part II when the advisor issues a card or PIN packet to an individual out of the office.

Advisor Issued Card

PAN — Enter the PAN from the card.

Advisor Issued PIN Packet

Control Number — Enter the PIN control number from the PIN packet.

Card Registration Required — Check this box if the card was given to someone other than the primary cardholder.

Individual’s Signature — The person receiving the card and/or PIN packet must sign the form to acknowledge receipt.

Requestor’s Signature — The advisor requesting issuance, cardholder PIN self-selection and/or data entry signs the form and enters an employee number and the date of request.

Signature of Person Completing Request — The EBT issuance staff who provides the card/PIN issuance/self-selection and/or data entry signs the form and enters an employee number and the date the requested action is completed.