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Official source

COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM

INTERNAL ACTION AND VAULT EBT CARD AUTHORIZATION FOR DISASTER BENEFITS

DATE: __________________

TO: _____ Vault Card Issuance Unit _____ EBT Administrative Terminal Personnel

FROM: BPS/Supervisor: ________________________ Telephone Number: _____________

RE: Case Name: __________________________________ Case Number: _________________

Amount Authorized: $ _______

Household Size: _______

I. Authorization for a Vault EBT Card

Vault card reason: (1) Timely processing (2) Household emergency (3) Agency determination

Case Name Social Security Number ___________________ Case Name Birth Date ________________

Address of household: ___________________________________________________________________

[ ] Release vault card to Authorized Representative ___________________________________________

II. Authorization for crediting the card replacement fee to the household’s account

Reason: Household disaster Lost in the mail Household Violence

Improperly manufactured Reapplication, no card Cardholder name changed

III. Administrative error – Debit account for $ __________________.

IV. Repay SNAP Claim of $ _________ from EBT account

Issuance/Administrative Unit Use

I. EBT Vault Card Number: 6 2 2 0 4 4

Type of identification seen:

Driver’s License Rent/Utility Bill/Receipt School ID Card Work ID Card

Library Card

Social Security Card Other: ________________________

I acknowledge that I received my EBT card. I understand that I need to call the Automated Response Unit (ARU) to select a Personal Identification Number (PIN) to use my benefits.

______________________________________________ _______________________________ Applicant or Authorized Representative Signature or Mark Date

Cardholder failed to pick up vault card Card destroyed on ____________ Vault card not prepared

II. Replacement fee credited on ______________

III. EBT account debited for $ _____ for an administrative error on ____/_____/_____

IV. Repaid $ ______ to SNAP Claim on ____/_____/_____.

Completed By: ____________________________________ _______________________________

Issuance/Administrative Worker Date

032-03-0664-03-eng (09/2024)