STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR CASH AID ELECTRONIC BENEFIT TRANSFER -
DATE
EBT EXEMPTION
CLIENT NAME
CASE NUMBER
The County will look at the facts I give to decide how my cash aid will be given to me.
I do not want to get cash aid by EBT because:
I have a Temporary Condition that prevents me from using EBT. *
I have a Permanent Condition that prevents me from using EBT. *
*You need to get written verification from your medical provider unless you have a condition that is readily apparent or has
been previously documented within sixty (60) days from this request that says what the condition is that prevents you from
using EBT and the expected duration of the condition.
Other (Explain ):_______________________________________________________________________________
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Verification provided?
Yes
No
Not needed
Exemption granted?
Yes
No, continue EBT
If Yes, alternate method to be used:
Direct Deposit
Warrant
CLIENT SIGNATURE
PHONE
DATE CLIENT NOTIFIED
WORKER’S INITIALS
WORKER’S NAME:
WORKER’S NUMBER
TEMP 2203 (7/02) REQUIRED FORM - SUBSTITUTE PERMITTED