Form H1854, Affidavit for Unauthorized Use of Electronic Benefit Transfer (EBT) Benefits

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Documents

Effective Date: 5/2023

Instructions

Updated: 7/2023

Purpose

  • To obtain a written statement and transaction details from a SNAP household about unauthorized transactions on their Lone Star Card. 
  • To provide a record of a person's statement for use if HHSC discovers perjury or an intentional program violation. 

Procedure

When to Prepare

Complete Form H1854 before replacing SNAP benefits removed from the household’s Lone Star Card without their authorization.

Number of Copies

Prepare an original.

Transmittal

Save a copy and any other documentation in the electronic case record and notify the designated HHSC staff determining the unauthorized use replacement eligibility.

Detailed Instructions

HHSC local office staff should verify the head of household’s (HOH’s), responsible household member’s or authorized representative’s (AR’s) identity. Complete Part IV of the form. Ensure that the person reads and understands the form. Witness them sign and sign as a witness to complete Part V of the form.

If the person cannot come to the HHSC local office to complete Form H1854, staff must:

  • allow a household member or AR to take the form to the person and physically return it to the HHSC local office; or
  • mail the form to the person with a postage paid return envelope; and 
  • instruct the household to call the Lone Star Help Desk at 800-777-2328 or login to their Your Texas Benefits mobile app to request a replacement Lone Star Card and select a new personal identification number (PIN).

The HHSC local office mails Form H1854 only for a person who:

  • is 60 or older; 
  • has a disability; or
  • has difficultly with the distance to the HHSC local office; and
  • cannot appoint an AR.

Part I

How to Find Your Lone Star Card Transaction History — Provides details on how a household can access their Lone Star Card transaction history details to complete Part II with the unauthorized transaction date(s) and amount(s).

Part II

Claim of Unauthorized Use of EBT Benefits — An HOH, responsible household member or AR completes Part II by completing the table and checking the box to confirm that the household’s SNAP benefits were used without authorization.

Transaction Date — Enter the date of the unauthorized transaction(s).

Transaction Amount — Enter the amount of the unauthorized transaction(s).

Retailer — Enter the retailer or store name where the authorized transaction(s) happened.

Retailer Address — Enter the retailer or store’s street address, city, state, and zip code where the authorized transaction(s) happened.

If more than five transactions are unauthorized, submit additional transactions on a separate sheet of paper. Households may use the instructions in Part I or call the Lone Star Help Desk at 800-777-7328 to get transaction(s) details, if unknown. HHSC local office staff may help households access their Lone Star Card transaction history using YourTexasBenefits.com on a lobby computer.

Part III

Explanation of Unauthorized Use Transactions — A HOH, responsible household member or AR completes Part III by checking the boxes and providing details of the unauthorized transactions, if known.

1. My SNAP household is still in physical possession of our Lone Star Card. — Check yes or no.

2. I believe my household's SNAP benefits were used without authorization from our Lone Star Card by one of the following fraudulent methods: — Check one of the following boxes.

  • Card Skimming — A device attached to a point-of-sale (POS) machine or PIN pad;
  • Card Cloning — An electronic scanner used to manually re-enter or create a physical copy of the card;
  • Unknown; or 
  • Other.

3. I know more information than the details in Part II of this form about the unauthorized transactions on my household’s Lone Star Card: — Check yes or no. If the HOH, responsible household member or AR checks yes, they should write the additional details of the unauthorized transactions listed in Part II that are known to the household on the lines below.

Part IV

SNAP Household Information — HHSC local office staff complete Part IV with the head of household’s (HOH’s) information. The HOH should also be the primary cardholder on the EBT account.

Case No. — Enter the household’s case number.

HHSC Office — Enter the HHSC local office accepting the signed Form H1854.

Case Name — Enter the name of the HOH as listed in the case record.

Current Mailing Address — Enter the street address where the household receives mail.

City — Enter the city where the household receives mail.

State — Enter the state where the household receives mail.

ZIP Code — Enter the five-digit ZIP code where the household receives mail.

Date of Discovery — Enter the date the household discovered their SNAP benefits were used without their authorization. 

Date Reported to HHSC — Enter the date the household received Form H1854 in the HHSC local office or the date the form was mailed.

Date HHSC Received Form H1854 — Enter the date HHSC received the signed form.

Part V

Affidavit Signature — The HOH, responsible household member or AR must provides identity verification before writing their name in the first blank and signing the form in front of staff.

Signature — Head of Household or Responsible Household Member — The HOH, responsible household member or AR signs the form. HHSC local office staff must witness the person signing the form unless the form was mailed. By signing Part V, the HOH, responsible household member or AR attests that a replacement Lone Star Card and PIN have been requested by the household. The person signing the form is also swearing under penalty of perjury that the transactions listed on the form were unauthorized by the household. 

Date — The person signing the form enters the date that HHSC local office staff witnessed them signing the form or the date that they signed the form if mailed.

Signature — HHSC Local Office Staff — The HHSC local office staff signing the form are considered the person responsible for submitting the replacement request to designated HHSC staff to determine the household’s eligibility for an unauthorized use replacement benefit.

Note: If this affidavit is not requested from an HHSC local office within 30 calendar days of the household discovering the unauthorized use of their SNAP benefits, no replacement will be issued.