Effective Date: 
7/2021

Documents

 

Instructions

Updated: 7/2021

 

Purpose

To provide a method for:

  • The Primary Cardholder (PCH) to authorize a secondary cardholder.
  • Another responsible household member or HHSC staff to authorize a secondary cardholder under special circumstances.
  • The Electronic Benefit Transfer (EBT) vendor and HHSC EBT issuance staff to establish a secondary cardholder in the EBT system.

Procedure

When to Prepare

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

Number of Copies

Complete an original.

Transmittal

When processed by interview staff, provide the form to the EBT issuance staff for data entry into the EBT system. After data entry is complete, the form must be imaged and linked with the case record.

When processed by the EBT vendor, the PCH mails the completed form to the vendor using the self-addressed, postage-paid section of the form. The EBT vendor completes data entry into the EBT system to establish the secondary cardholder.

 

Detailed Instructions

Facts About You

610098 — These are the first six digits of each person’s Lone Star Card number. The PCH must enter the remaining digits from their unique Lone Star Card.

Last Name — The PCH must enter their last name exactly as it is spelled in their Texas Integrated Eligibility Redesign System (TIERS) case record.

Middle Initial — The PCH must enter their middle initial, if applicable.

First Name — The PCH must enter their first name exactly as it is spelled in TIERS.

Address — The PCH must enter their address exactly as it is listed in TIERS.

City — The PCH must enter their city.

State — The PCH must enter their state.

ZIP — The PCH must enter their ZIP code.

Facts About Secondary Cardholder

Last Name — The secondary cardholder must enter their last name.

Middle Initial — The secondary cardholder must enter their middle initial, if applicable.

First Name — The secondary cardholder must enter their first name.

Gender of Secondary Cardholder — The secondary cardholder must mark either “female” or “male.”

Date of Birth — The secondary cardholder must enter their date of birth.

Social Security Number — The secondary cardholder must enter their Social Security number. If they cannot provide a Social Security number, have the person enter "None" on this line.

Signature of Secondary Cardholder — The secondary cardholder must sign this section.

Date — The secondary cardholder enters the date they signed this form.

Your Signature — The PCH must sign this section. If interview staff complete the form to authorize a secondary cardholder, they complete the PCH information and sign in the section marked "Your Signature."

Date — The PCH (or HHSC staff, if applicable) enters the date they signed this form.