Form Temp 2203 - Request For Cash Aid Electronic Benefit Transfer - Ebt Exemption

Download a blank fillable Form Temp 2203 - Request For Cash Aid Electronic Benefit Transfer - Ebt Exemption in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Temp 2203 - Request For Cash Aid Electronic Benefit Transfer - Ebt Exemption with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

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 ):_______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go