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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES DIVISION OF BENEFIT PROGRAMS

INTERNAL ACTION AND VAULT EBT CARD AUTHORIZATION

TO:  Vault Card Issuance Unit  EBT Administrative Terminal Personnel Date ___/___/___

FROM: Benefit Program Specialist/Supervisor: ____________________________ Telephone: ____________

RE: Case Name: ___________________________________ Case Number: _______________________

I.  Authorization for a Vault EBT Card

Vault card reason:  Timely processing  Household emergency  Agency determination

PCH Social Security Number ___________________________ PCH Birth Date ___/___/___

 Issue a vault card to Authorized Representative ___________________________________________

Address of vault card recipient: ____________________________________________________________

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

 Other ______________________________________________

III.  Administrative error – Debit account for $__________

IV.  Repay SNAP Claim of $_________ from EBT account

Issuance/Administrative Unit Use

I. EBT Vault Card Number: ______________________________ Card destroyed on _____/_____/_____

Type of identification seen:  Driver’s License  Rent/Utility Bill/Receipt  School ID  Work ID  Library Card

 Social Security Card  Other ________________________________

I acknowledge that I received my EBT card or that I received the card on behalf of another household. I understand that I need to select a Personal Identification Number to use my benefits.

__________________________________________________ _____________________________

Cardholder's Signature

Date

 Cardholder failed to pick up vault card  Card destroyed  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

032-03-0387-07-eng (09/2024)