Form H1111, Card Order Discrepancy Verification

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Effective Date: 6/2004


Updated: 7/2006


To provide local office staff with a method of verifying EBT card order discrepancies.


When to Prepare

The local office prepares this form immediately upon discovering a card order discrepancy.

Number of Copies

Prepare one self-carboning form.


The local office retains the original for audit purposes and faxes a copy to the EBT Regional Security Officer.

The EBT Regional Security Officer retains a copy and faxes a copy to the

  • Security Manager, LST, (512) 206-5961; and
  • Deputy Project Manager, ACS, (512) 401-8220 or (512) 401-8221

Form Retention

Retain the original for three years.

Detailed Instructions

1. Order Number — Enter the order number that contains the discrepancy.

2. Date Ordered — Enter the date ordered.

3. Date Order Received — Enter the date the order was received in the local office. Indicate by marking the check box whether the discrepancy is a shortage or an overage.

Section I: Verification of Shortage

Number — Enter the number of cards the order was short.

Missing Sequence Numbers — Enter the sequence number(s) for the missing cards.

Section II: Verification of Overage

Number — Enter the number of excess cards.

Extra Sequence Numbers — Enter the sequence numbers of the extra cards.

EBT security procedures require that two persons in the local office verify the discrepancy. The first person completes Items4 through 10 and the second person completes Items 11 through 17.

4. and 11. Signature — Local office staff signs to verify the discrepancy.

5. and 12. Name — Print the name of the local office staff person verifying the discrepancy.

6. and 13. Title — Enter the title of the person verifying the discrepancy.

7. and 14. Office — Enter the office name and address.

8. and 15. Mail Code — Enter the office mail code.

9. and 16. Phone Number — Enter the phone number, including area code, of the person verifying the discrepancy.

10. and 17. Date — Enter the date the form is completed.

18. Comments — Enter comments explaining the situation.