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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES DIVISION OF BENEFIT PROGRAMS
VAULT EBT CARD ISSUANCE LOG
Agency/Location ______________________________________________
Month __________ Year __________
Date
Case Number
Cardholder Name Reason for Vault Card (1, 2, 3) Card Number (16 digits) Issued By (Initials) 1.
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032-03-0391-00-eng (10/01)