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VIRGINIA DEPARTMENT INTERNAL ACTION AND OF SOCIAL SERVICES VAULT EBT CARD AUTHORIZATION

10/24 VOLUME V, PART XXIV, PAGE 76

Internal Action and Vault EBT Card Authorization

FORM NUMBER - 032-03-0387

PURPOSE OF FORM - The Certification Unit will use this form to communicate with the Issuance or Administrative Unit in the local agency.

USE OF FORM - The BPS must complete the top portion of the form to authorize the Issuance Unit to prepare and issue a vault card to an eligible household or authorized representative. The Benefit Program Supervisor must complete the top portion of the form to authorize the Issuance or Administrative Supervisor, as designated by the agency, to credit the card replacement fee to a household's EBT account. The Issuance or Administrative Unit must complete the bottom portion of the form to document the action taken. The primary cardholder or authorized representative must also sign the form to acknowledge receipt of the vault card. The agency must use the internal action form to document repayment of a claim with funds in an EBT account or to debit an account for an administrative error.

NUMBER OF COPIES - Three.

DISPOSITION OF FORM - The BPS or Supervisor must retain a copy of the form and forward the remaining copies to the Issuance or Administrative Unit for completion. The Issuance or Administrative Unit must retain a copy of the fully completed form and return the second copy to the Certification Unit. Upon receipt of the form, the BPS or Supervisor must file the copy in the case file. The initial copy completed only by the BPS may be discarded.

INSTRUCTIONS FOR PREPARATION OF FORM - The BPS or Supervisor must complete the identifying case and unit information. The BPS or Supervisor must complete the appropriate section of the top portion of the form to explain or authorize actions, including Section I to note why a vault card is necessary. The BPS must include the address of the person who will receive the vault card, either the primary cardholder or authorized representative, for entry in the EBT system. The BPS may attach a copy of the VaCMS inquiry to avoid transcription errors.

The Benefit Programs Supervisor must complete Section II to authorize crediting the card replacement fee back to the household's EBT account. The Benefit Programs Supervisor must also complete Section III to debit benefits from an account that were erroneously deposited as a result of an administrative error.

The Issuance Unit must promptly act to prepare a vault card for a household upon receipt of the form completed by the BPS or Supervisor. The Issuance Worker must obtain and record identity verification before releasing the vault card and secure the signature of the primary cardholder or authorized representative on the form.

The completed form must remain with a prepared vault card until the cardholder comes to the agency. The Issuance Unit must destroy the card after five business days if the cardholder does not receive it or make additional arrangements to receive the card. The Issuance Worker must note the date of the destruction of the card on the form. If the agency opts to wait until the

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