To provide a means to account for Lone Star cards.
When to Prepare
The EBT site coordinator, or their back-up, who are responsible for maintaining a supply of Lone Star Cards, must complete this form at the end of each month.
Number of Copies and Transmittal
- An original is maintained in each certification office.
- A copy is sent to the EBT regional coordinator.
Note: Use one Form H1174 for Lone Star cards and a separate form for PIN packets.
All copies of the form are retained as specified in the Manager's Guide for Eligibility Programs.
Region No. — Enter the region number.
Unit No. — Enter the unit number.
Mail Code — Enter the office mail code.
Date — Enter the date the form was completed.
Month of Report — Enter the month of report.
Note: For Part I through Part IV, report the inclusive set of serial numbers for the EBT cards received, issued and on hand. Report the serial numbers in the proper sequence. Do not report non-continuous sequence numbers as if they were continuous: for example, 9200001 through 9220009 and 9228815 through 9228845 should be reported as two separate entries because there is a gap in the sequence numbers. Do not report as 9200001 through 9228845. Make as many entries as needed to account for the serial numbers of each card issued. To determine the sequence number on Lone Star Cards, disregard the last digit of the PAN.
Part I — Enter the total number of Lone Star Cards on hand at the beginning of the month and the inclusive serial numbers.
Part II — Enter the number of Lone Star cards received during the month of report and the inclusive serial numbers.
Part III — Enter the total number of Lone Star cards used during the month of report and the inclusive serial numbers.
Part IV — Enter the total number of Lone Star cards on hand at the end of the month and the inclusive serial numbers.
Note: The total number of Lone Star cards on hand at the beginning of the month should be same amount reported in Part IV at the end of the preceding month.
Signature of Responsible Staff Member — The staff member responsible for completing the form must sign.
Date Revised — Enter the date the form was revised.
Name of Responsible Staff Member — Enter the name of the staff member responsible for completing the form.
Title — Enter the title of the staff member responsible for completing the form.
Office City Location — Enter the city in which the office is located.
Note: The staff member’s signature validates that a physical count was made and verifies the numbers reported are consistent with the results of the physical count.