Form H1173, EBT Card Issuance Log

Instructions for Opening a Form

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Effective Date
H1173.pdf (109.19 KB)


Updated: 1/2022


  • To serve as a log of issued Lone Star Cards.
  • To provide a record of issued Lone Star Cards by cardholder, Eligibility Determination Group (EDG) number and issuance staff.


When to Prepare

Enter the information on Form H1173 for each card issued in sequential order.

When a card is issued in the office, the person receiving the card must sign the log to confirm receipt. Ensure all previously recorded recipient information is covered, to ensure confidentiality.

Number of Copies

Each certification office maintains an original.


At the end of each month, file the log according to procedures in the Eligibility Operations Procedure Manual (EOPM) EBT Appendix.

Detailed Instructions

Replacement — If using the form to log a replacement card, write "R" in the Replacement column. If a local office is replacing a card because the Lone Star Help Desk failed to replace it timely, then write “VR” to identify the vendor replacement on Form H1173, and report the total to the EBT regional coordinator or their back-up at the end of each month. The EBT regional coordinator or their back-up reports the regional total by the 15th day of the next month to Lone Star Business Services.

Issue Date — Enter the Lone Star card issue date.

Note: If logging out a card to take on a home visit, staff enter the date the item is issued.

Name of Primary Cardholder — Enter the name of the primary cardholder.

Note: If returning an unused card previously logged out for a home visit, staff write "returned/wkr" in this box and return the card to inventory.

EDG No. Enter the Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) EDG number associated with the card being issued. Ensure the card is linked to both program EDGs, if applicable.

Note: Leave this box blank when logging a returned card.

Card No. (PAN) — Enter the 19-digit personal account number (PAN) from the card when logging an issued card. Note: Use the excel macro version to generate the PANs on the form.

Card Recipient — Enter an abbreviation for the person receiving the card:    

  • AHM – Enter “AHM” if another adult household member received the card;
  • AP – Enter “AP” if an alternate payee received the card;
  • AR – Enter “AR” if the authorized representative received the card;
  • PCH – Enter “PCH” if the primary cardholder received the card; or
  • SCH – Enter “SCH” if the secondary cardholder received the card.

PIN Self-selection — Enter “Yes” if the card recipient is able to self-select a PIN. Enter “No” if the card recipient does not self-select a PIN. Enter “N/A” if the card recipient is not authorized to select to self-select a PIN.

Signature of Recipient — When a person receives a card in the office, they must sign here.

Note: If logging out a card to take on an out-of-office interview, staff must sign here.

Issuance Staff Initials and Emp. No. — Issuance staff initial and list their employee number when issuing a card.