Form Gen 1391 - Cdss Eievs Access Request Form
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CDSS eIEVS ACCESS REQUEST FORM
The CDSS electronic Income and Eligibility Verification System (eIEVS) Access Form is used to authorize, change
and terminate access to the eIEVS containing CDSS data. The information on this form must be kept current. It must be
signed by the appropriate User Supervisor and System Administrator(s). It must also be signed by the user before he/she
obtains access. (Once completed, all County and Non-CDSS State staff must submit this form to
fraudsystemaccess@dss.ca.gov mailbox for approval.)
Section 1 – Access Request:
Level of Access Requested:
User
Administrator (go to Section 2)
Role Requested (Check all that apply):
Coordinator
FTI Supervisor
FTI Match Assigner
FTI Reviewer
(attach FTI certification)
(attach FTI certification)
(attach FTI certification)
Desk: _______________
Non-FTI Supervisor
Non-FTI Match Assigner
CDSS User
Non-FTI Reviewer
Desk:________________
Requested Action:
Add User
Delete User
Edit User
Section 2 – User Information
(To be completed by the requesting individual. For administrator access, please
)
complete Section 2 only
________________________________________________________________________
User Name:
Last Name
First Name
Middle Initial
____________________________________________________________________
Company Name:
__________________
______________________________________
Phone Number:
Email Address:
User Acknowledgement and Signature:
This section is to be read and completed by the user prior to receiving access to eIEVS.
I will access the system for appropriate business purposes only. I will take all appropriate precautions to protect the
confidential and sensitive data in the system as detailed in the security policies and guidelines provided by my employer.
Submitted by:
_________________________________________________________________________________
User’s Name (Print)
User’s Signature
Date
_________________________________________________________________________________
Supervisor’s Name (Print)
Supervisor’s Signature
Date
_______________ _________________________________________________________________
Supervisor’s Phone
Supervisor’s Email
Section 3 – Administrator Approval:
(This section to be completed by the administrator granting access to
County users only – leave blank if Administrator Level access is requested above)
Administrator Authorization Signature (The below administrator must be on the approved CDSS administrator list):
I certify that the above employee may be granted access to the systems indicated for the above county.
_________________________________________________________________________________
Administrator’s Name (Print)
Administrator’s Signature
Date
GEN 1391(6/17)
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