Form H1172, EBT Card, PIN and Data Entry Request

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Effective Date
H1172.pdf (214.44 KB)
H1172-S.pdf (214.64 KB)


Updated: 10/2021


To provide a method for the:

  • interview staff to manually request Electronic Benefit Transfer (EBT) issuance staff send the primary cardholder (PCH) record to the EBT system.
  • EBT site coordinator or designated staff to authorize the EBT issuance staff to use the EBT system to register a cardholder’s card when it cannot be done over the phone with the Lone Star Help Desk.
  • interview staff to request EBT issuance staff:
    • issue a Lone Star Card;
    • enable a cardholder to self-select a PIN; and
    • enter the personal account number (PAN).
  • interview staff to:
    • notify EBT issuance staff a Lone Star Card was delivered on a home visit to a PCH; and
    • request EBT issuance staff enter the PAN.


When to Prepare

When manual EBT card issuance is needed for a Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) EDG and the person needs (or upon certification will need) access to the cash or food account.

Number of Copies

Complete an original for each PCH who needs validation or issuance of a Lone Star Card.


Interview staff give the original to EBT issuance staff.

Detailed Instructions

Name of Primary Cardholder — Enter the name of the PCH exactly as it is spelled in the Texas Integrated Eligibility Redesign System (TIERS).

TANF and SNAP EDG Numbers — Enter the TANF or SNAP EDG number for which the card is being issued or for which a PIN is being self-selected by the cardholder. If the card or PIN is for both a TANF and SNAP EDG, enter both EDG numbers.

Date of Birth — Enter the PCH’s date of birth (mm/dd/yyyy).

Gender — Check either F (female) or M (male) to indicate the PCH’s sex.

Social Security Number (SSN) — Enter the PCH’s SSN. If the cardholder cannot provide an SSN or does not have an SSN, enter zero.

Mailing Address, City, County, State, ZIP — Enter the address to which EBT-related materials should be delivered. This would normally be the TIERS case mailing address, unless there is an EBT representative for the EDG. If there is an EBT representative, use that person's address on the form and ensure the Issuance — Details and Issuance — Address pages in TIERS also reflect that there is a different issuance address than the case mailing address.

EDG Name — Check Yes or No to indicate whether the PCH’s name is also the EDG name.

Note: If the name of the PCH is the same as the EDG name, manually select Yes in the EDG Name field after generating the form or leave the field blank. If the name of the PCH is not the same as the EDG name, select No.

Part I

Request for Issuance — The advisor completes Part I to request that EBT issuance staff issue a card to a person in the office or by mail.

Name of Person to Receive Card — Enter the name of the person to whom the card must be given or mailed.

Date and Time — Enter the date and time of the request.

Card Action Requested

  • Issue — Check this box if a card needs to be issued to a person in the office.
  • Mail — Check this box if a person needs a card issued by vendor mail.
  • Replace — Check this box if a person has an active SNAP or TANF EDG and needs a replacement card issued.
  • Pend Registration — Check this box if the card was given to someone other than the PCH in the office or mailed to the PCH.

Note: Cards do not need to be registered if they are issued directly to the PCH, and the PCH selects a PIN on the PIN pad device in the local office.

If TANF Protective Payee — Mailing Address — Enter this address if a card must be mailed to a TANF protective payee.

How was identity verified when the card was issued? — Describe how the cardholder's identity was verified when the card was issued in the local office. Cards mailed by the vendor do not require identity verification. Box can be left blank. No further information is required.

Note: When the card is issued in the local office and identity is verified by a driver's license, military identification (ID), or other ID card with an identifying number, enter the type of ID and the ID card number listed.

Part II

Notification of Issuance — Complete Part II when issuing a card or if card registration is required for a person outside of the office.

Advisor Issued Card — Check this box if the advisor issued a card to a person during a home visit or itinerant office interview.

PAN — Enter the PAN from the card.

Pend Registration — Check this box if the card was given to someone other than the PCH or if the PCH needs to select a PIN.

Individual’s Signature — The person receiving the card must sign and date the form to acknowledge receipt.

Requestor’s Signature — The advisor requesting issuance signs the form and enters their employee number and the date of request.

Signature of Person Completing Request — EBT issuance staff sign the form and enter their employee number and the date the requested action is completed.