Form H1177, Transmittal and Receipt for Controlled EBT Documents

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Effective Date: 4/2018


Updated: 4/2018


  • To serve as a transmittal and receipt memorandum accompanying supplies of Lone Star cards or other controlled EBT documents.
  • To provide a security and accounting mechanism for controlled EBT documents.


Regional and local offices use Form H1177 as a receipt for controlled EBT documents. Only persons who are authorized to maintain a supply of controlled documents and who are named in the local office security chart may sign this form.

Number of Copies

Complete an original and two copies.


The person sending the controlled documents sends the original and first copy of Form H1177 with the documents. The sender keeps the second copy as a control document until the receiver signs and returns the original.

The person who receives the controlled documents signs the original and first copy, returns the original to the sender, and retains the first copy for the office's inventory file.

Form Retention

Retention requirements are found in the Manager's Guide for Eligibility Programs.


To— Enter the name and address of the person designated to receive the controlled documents.

From— Enter the name and address of the person sending the controlled documents.

Check the appropriate box to indicate the type of document. Enter the total number and inclusive serial numbers of documents being sent. The person sending the controlled documents signs and dates Form H1177. The person receiving the controlled documents signs and dates Form H1177 and marks through any blanks not used.