Form Temp 2201 - Cash Aid/food Stamp Electronic Benefit Transfer - Ebt Request For A Designated Alternate Card Holder/authorized Representative

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASH AID/FOOD STAMP ELECTRONIC BENEFIT TRANSFER - EBT
REQUEST FOR A DESIGNATED ALTERNATE CARD HOLDER/AUTHORIZED REPRESENTATIVE
CASE NAME:
WORKER NAME
CASE NUMBER:
DATE:
INSTRUCTIONS:
A Designated Alternate Card Holder/Authorized Representative is a responsible person that you trust. A Designated
Alternate Card Holder/Authorized Representative will have an EBT card issued in their name and the card
holder/authorized representative, you choose will have access to all your cash aid or food stamp EBT.
Tell us the name and birthdate of the person you want to be a Designated Alternate Card Holder/Authorized
Representative
Sign and complete this form
Send or bring in the form to your County Office
Designated Alternate Card Holder
Authorized Representative
New
Change
Remove
NAME OF REQUESTED DESIGNATED ALTERNATE CARDHOLDER/AUTHORIZED REPRESENTATIVE
BIRTHDATE
CERTIFICATION:
I understand the person I make Designated Alternate Card Holder/Authorized Representative will have access to ALL of
my cash aid and/or food stamp EBT. The County is not responsible for lost or stolen benefits. I can change who can
access my cash aid or food stamps by calling my County Worker.
SIGNATURE
PHONE
DATE
To be signed by Designated Alternate Card Holder/Authorized Representative
I agree to be a Designated Alternate Card Holder/Authorized Representative. By using this card, I agree to the terms of
the cash aid/food stamp Electronic Benefit Transfer - EBT program.
DATE
DESIGNATED ALTERNATE CARD HOLDER/AUTHORIZED REPRESENTATIVE SIGNATURE
Report lost or stolen card IMMEDIATELY by calling toll free 1-877-328-9677.
REMINDER
It is YOUR responsibility to call the toll-free customer service telephone number (1-877-328-9677) to terminate another
household member’s, Designated Alternate Cardholder’s, or Authorized Representative’s access to your EBT account.
TEMP 2201 (7/02) REQUIRED FORM - SUBSTITUTE PERMITTED

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