Form H1173, EBT Card Issuance Log

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Documents

Effective Date: 1/2022

Instructions

Updated: 1/2023

Purpose

  • To serve as a log of issued Lone Star Cards.
  • To provide a record of issued Lone Star Cards by cardholder, Eligibility Determination Group (EDG) number and issuance staff.

Procedure

When to Prepare

Enter the information on Form H1173 for each card issued in sequential order.

When a card is issued in the office, the person receiving the card must sign the log to confirm receipt. Ensure all previously recorded recipient information is covered, to ensure confidentiality.

Number of Copies

Each certification office maintains an original.

Transmittal

At the end of each month, file the log according to procedures in the Eligibility Operations Procedure Manual (EOPM) EBT Appendix.

Detailed Instructions

Replacement — To record the issuance of a replacement card, write "R" in the Replacement column. If a person previously requested a replacement card from the Lone Star Help Desk and did not receive the card within seven calendar days after the order date, issue a replacement card and write “VR” for vendor replacement on Form H1173. Report the total vendor replacements to the EBT regional coordinator, or their back-up, at the end of each month. The EBT regional coordinator, or their back-up, reports the regional total to Lone Star Business Services by the 15th day of the next month.

Issue Date — Enter the Lone Star card issue date.

Note: If logging out a card to take for a home visit interview, enter the date the card is issued (date of the home visit).

Name of Primary Cardholder — Enter the name of the primary cardholder.

Note: If returning an unissued card previously logged out for a home visit interview, write "returned/wkr" in this box and return the card to inventory.

EDG No. — Enter the Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) EDG number associated with the card being issued. Ensure the card is linked to both program EDGs, if applicable.

Note: Leave this box blank when logging a returned card.

Card No. (PAN) — Enter the 19-digit personal account number (PAN) from the card to log an issued card.

Note: Use the excel macro version to generate the PANs on the form.

Card Recipient — Enter an abbreviated description for the person receiving the card. If card recipient is:

  • another adult household member, enter “AHM”;
  • an alternate payee, enter “AP”;
  • the authorized representative, enter “AR”;
  • the primary cardholder, enter “PCH”; or
  • the secondary cardholder, enter “SCH”.

PIN Self-selection — Enter “Yes” if the card recipient is able to self-select a PIN. Enter “No” if the card recipient does not self-select a PIN. Enter “N/A” if the card recipient is not authorized to select to self-select a PIN.

Signature of Recipient — The person receiving a card in the office must sign here.

Note: If logging out a card to take on a home visit interview, staff must sign here.

Issuance Staff Initials and Emp. No. — Issuance staff must enter their initials and employee number when issuing a card.