Fillable CASH AID/FOOD STAMP ELECTRONIC BENEFIT TRANSFER - EBT (California)

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CASH AID/FOOD STAMP ELECTRONIC BENEFIT TRANSFER - EBT (California)

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SIGNATURE
DATE
PHONE
DATE
DESIGNATED ALTERNATE CARD HOLDER/AUTHORIZED REPRESENTATIVE SIGNATURE
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
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.
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.
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
NAME OF REQUESTED DESIGNATED ALTERNATE CARDHOLDER/AUTHORIZED REPRESENTATIVE
BIRTHDATE
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CASH AIDFOOD STAMP ELECTRONIC BENEFIT TRANSFER - EBT (California)

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Completed 17 August 2021

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