Form H1172
Instructions

EBT Card, PIN
and Data Entry Request

05-2013

PURPOSE

  • To provide a method for the advisor to request Electronic Benefit Transfer (EBT) issuance staff to
    • 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
    • data enter the personal account number (PAN) and PIN control number.
  • To provide a method for the advisor to request EBT issuance staff to determine if a previously issued Lone Star card currently held by an individual can be used to access benefits on the specified accounts, 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 EBT issuance staff to data enter the PAN and PIN control number.
  • To provide EBT issuance staff with information needed to
    • locate the primary cardholder record through inquiry into the Administrative Terminal Application, and
    • data enter the PAN and/or PIN control number.

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 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

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

TANF and SNAP EDG No. 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 when requesting a card to be issued 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.

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.

Issue/Validate Card Check this box if completing a manual Form H1172 and/or:

  • select Issue Card in TIERS or circle Issue on the manual Form H1172, if a card needs to be issued to an individual in the office; or
  • select Validate Card in TIERS or circle Validate when using the manual Form H1172, 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 Identity Verified When Card Issued in Local Office? Describe how the cardholder's identity was verified when the card was issued in the local office. Note: Enter identification (ID) card number when identity is verified by a Texas Driver's License, military ID, or other ID card when the card is issued to the Primary Cardholder in the local office.

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/Control Number — Enter the PAN/Control Number from the card.

Advisor Issued PIN Packet 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.

Client Signature The person receiving the card and/or PIN packet must sign the form to acknowledge receipt.

Requestor 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.

Request Completed by The EBT issuance staff who provide card/PIN issuance/self-selection and/or data entry sign the form and enter an employee number and the date the requested action is completed.