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Downloading a Form to Your Computer
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- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
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- A method for the advisor to manually request Electronic Benefit Transfer (EBT) issuance staff send a Supplemental Nutrition Assistance Program (SNAP) benefit record to the EBT system when the Texas Integrated Eligibility Redesign System (TIERS) is unavailable.
- The advisor with a method to give EBT issuance staff the authorization and information needed to enter information into the EBT system for updated primary cardholder (PCH) and benefit records.
- A method for the advisor to request an update to the PCH record when it cannot be done in TIERS.
- A method for the advisor to request EBT issuance staff use the EBT system to split PCH records when a cardholder's EDG is linked in error to another EDG belonging to another PCH.
- A method for the advisor to request EBT issuance staff manually merge one PCH record to another PCH record belonging to the same individual through the EBT system, so both the EDGs are linked to a single cardholder record.
When to Prepare
The advisor or authorized staff complete the form when it is necessary to use the EBT system to:
- send SNAP priority benefit records;
- update the PCH record; or
- split or merge PCH records.
Number of Copies
The advisor or authorized staff person completes the original.
The advisor or authorized staff person gives the original to EBT issuance staff.
Send SNAP Priority Benefit Record — Complete Part I when it is necessary to send a priority benefit using the EBT system. Complete the line beginning with Second Month only to send a benefit record for the second month of a combined allotment.
SNAP EDG Number — Enter the SNAP EDG number.
Primary Cardholder Name — Enter the name of the PCH as it is spelled in EBT.
First Month — Enter the first month the household will receive SNAP benefits.
Second Month — Enter the second month the household will receive SNAP benefits.
No. in Household — Enter the number of household members certified to receive SNAP in the first and second months.
Benefit Month — Enter the benefit month (mm/dd/yyyy) for the first and second months.
Allotment Value — Enter the dollar value of SNAP benefits the household is entitled to receive in the first and second months. Enter the amount ensuring there is no room to enter extra figures after the $ sign or before the amount (for example, $**75.00).
County No. — Enter the county code.
Type — Check the box for the first month to indicate if the EBT issuance is for "expedited" service or to meet "timeliness" requirements. Note: For the second month of a combined allotment, the benefit type is always "timely."
Form H1855 signed? — Check the box to indicate Yes or No.
TIERS inquiry completed? — Conduct inquiry to ensure the household has not received benefits already. Check the box to indicate Yes or No.
Reason — Enter the reason for issuing benefits through manual data entry in the EBT system rather than through TIERS.
Supervisor's Review — The supervisor or a person designated by the supervisor:
- reviews Form H1175 to ensure:
- checks Yes or No that the application and supporting documents were reviewed; and
- initials Form H1175 and enters the reviewer's employee number and review date.
Note: The supervisor is not allowed to approve an EBT system issuance unless an application for SNAP or TANF benefits is on file.
Update Primary Cardholder Record — Complete Part II when the EBT System must be used to update the PCH record.
Primary Cardholder Name, TANF or SNAP EDG No. — Enter the PCH's name and EDG number(s) as listed in TIERS.
Update the primary cardholder record as follows: — Enter the new information only in the fields that require an update.
Primary Cardholder Name — Enter the updated name of the PCH.
Gender — Check either F (female) or M (male) to indicate the updated PCH’s sex.
Social Security Number (SSN) — Enter the PCH's updated SSN (if known). If the cardholder cannot provide an SSN or does not have an SSN, enter ”0.”
Mailing Address, City, State, ZIP — Enter the updated address to which EBT-related materials should be delivered.
Endorsement — (SNAP only) Indicate one of the following "prepared meals services" statuses, if applicable:
- Code "C" — communal dining, elderly/Supplemental Security Income (SSI) recipient
- Code "H" — homeless
- Code "M" — meal delivery, housebound/has a disability
- Code "E" — every service, homeless and elderly/SSI recipient
Otherwise, make no entry.
HOH — Check Yes if the PCH is also the Head of Household (HOH) or No if the PCH is not the HOH, if there was a change on the PCH.
EDG Name — Check Yes if the PCH’s name is the EDG name for the record that needs to be updated or No if the PCH’s name is not the EDG name, if there is a change on the PCH.
Split Primary Cardholder Records — The split function in the EBT system can only be done by the EBT regional coordinator.
The advisor completes Part III when a cardholder's EDG is linked to another EDG in error. This situation may occur for various reasons, but it usually happens when the advisor changes the HOH on the case and fails to reassign the EDG name to the current HOH from the previous one.
- If staff become aware of a situation in which one person's PCH record for a SNAP EDG is erroneously linked to another person's PCH record for a TANF EDG, immediately report it through supervisory channels to the regional EBT coordinator or designated staff for correction.
EDG Name — Enter the EDG name for the record that needs to be split.
EDG Numbers — Enter the cardholder's TANF or SNAP EDG numbers that need to be split in the EBT system.
Note: The EDG name and EDG number box on the left will list the EDG that needs to be split from the account. The EDG name and EDG number listed on the right box will be the EDG staying on the current account and keeping the card active.
Merge Primary Cardholder Records — The advisor completes Part IV when a cardholder has a multiple EDGs that are not linked to the same PCH record in the EBT system, and the cardholder wishes to use one card to access benefits for both. In this situation, staff must use the EBT system to manually merge the PCH's two records and link both accounts to one card. The PCH record data must match before this procedure can be completed.
EDG Name — Enter the EDG name for the records that need to be linked.
EDG Numbers — Enter the cardholder's TANF or SNAP EDG numbers that need to be linked in the EBT system.
Note: The EDG name and EDG number box on the left will list the EDG that needs to be merged to the other account. The EDG name and EDG number listed on the right box will be the EDG merged to and with the current active card.
Requestor Signature — The advisor requesting the data entry signs the form and enters their employee number and the date of the request.
Signature of Person Completing Request — The EBT staff who perform data entry sign the form and enter their employee number and the date the requested action is completed.