Effective Date: 5/2016



Note: This is not an HHSC form. It is not available through this site. Contact the appropriate regional EBT staff for assistance.



Updated: 7/2014


  • To provide a method for the primary cardholder (PCH) to authorize a secondary cardholder.
  • To provide a method for another responsible household member or the advisor to authorize a secondary cardholder under special circumstances.
  • To provide a method for Electronic Benefit Transfer (EBT) vendor staff and Texas Health and Human Services Commission (HHSC) issuance staff to establish a secondary cardholder in the EBT database.


When to Prepare

When a household needs a secondary cardholder, the household may request the form the Lone Star Help Desk or the local HHSC benefits office.

Number of Copies

Complete an original.


When processed by staff, the form is given to the issuance staff for data entry into the administrative terminal application (ATA). After data entry is complete, the form must be imaged and linked with the case record.

When processed by EBT vendor staff, the household mails the completed form to the EBT vendor usingthe self-addressed, postage-paid section of the form. EBT vendor staff complete data entry into the ATA to establish the secondary cardholder.

Form Retention

Retain the form according to the requirements in the Texas Works Manager's Guide.

Detailed Instructions

The form includes instructions for completion and is self-explanatory. If the secondary cardholder cannot give a Social Security number, have the individual enter "None" on that line.

If the advisor is completing the form to authorize a secondary cardholder, the advisor completes the information on the PCH and signs in the section marked "Your Signature".