Form Ebt 2259 - Report Of Electronic Theft Of Cash Aid Page 4
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4REPORT OF ELECTRONIC THEFT OF CASH AID
Please list all electronic theft cash transactions below, if known:
DISPUTE CLAIM #
DATE
AMOUNT
NAME OF STORE
ADDRESS OF STORE
(if known)
$
$
$
$
$
$
$
TOTAL
If you have any additional information or details, please provide below:
I declare under penalty of perjury under the laws of the United States of America and the State
of California that the information I have given on this form is true, correct, and complete to the
best of my knowledge. I understand that if I, knowingly, give wrong information or leave out
information that I know to be true and I get cash aid that I am not eligible for, I will be responsible
for repayment, I can be disqualified from getting cash aid, I can be fined and I can be charged
with a crime.
SIGNATURE OF RECIPIENT
DATE
SIGNATURE OF CARDHOLDER (IF DIFFERENT FROM RECIPIENT)
DATE
COUNTY USE ONLY/FAX COPY TO CDSS: (916) 657-2207
DATE RECEIVED:
CASE NAME:
COUNTY:
CASE NUMBER:
COUNTY WORKER NAME:
WORKER PHONE NUMBER:
WORKER EMAIL:
EBT 2259 (11/13) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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