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EBT Forms
The following forms are used for EBT.
Electronic Benefit Transfer (EBT) On-Line Request (SCD 2201)
Usage
The Electronic Benefit Transfer (EBT) On-Line Request (SCD 2201) is to be used by the Eligibility Worker (EW) to request the DOFC to perform the following on-line transactions through CalSAWS, the EBT Administrative Terminal or the PIN machine, as appropriate:
- Status (Deactivate) an EBT card
- Record date EBT card returned to Benefit Issuance Unit
- Print an EBT card
- Change Issuance Method
- Activate Dormant Account
- Repay Benefits from EBT account
- Select/Change/Unlock PIN
- Set up account and/or add Primary Payee and/or Authorized Representative
- Add Emergency cash/Food Benefits (Requires EWS’ signature).
The SCD 2201 is also used by clerical staff to indicate an immediate need EBT card has been issued and to status (deactivate) a card that is returned to the County. The client is required to sign the form, as proof he/she received his/her EBT card and/or changed the PIN.
Note: The SCD 2201 may also be used to assist a client to change his/her PIN; however, if the request comes directly from the client and not the EW, clerical staff must use the “Client Electronic Benefit Transfer (EBT) Request” (SCD 2202) form.
Completion
The SCD 2201 is usually completed by the EW. It has two sections.
Section I
The actions requested in Section I are normally performed by the DOFC using the CalSAWS system. CalSAWS sends the data to the EBT system through an interface. ONLY in specific situations is the Administrative Terminal used to perform these actions.
The following actions are included in Section I:
- “Status EBT Card” - The EW completes this section, if he/she wants to have the DOFC deactivate an EBT card. Clerical staff may also complete this section when an EBT card is returned.
- “Date Returned to Benefit Issuance Unit” - Clerical Staff completes this section for returned EBT cards. The date the card is sent to the Benefit Issuance Unit to be destroyed is entered on this form.
- “Print EBT Card” - The EW completes this section if the client wants an EBT card issued in the office. This section MUST be completed if the EW is issuing an immediate need for a Primary Cardholder.
- “Change Issuance Method” - The EW completes this section to have the Issuance Method changed from “Transfer Batch” to “Transfer Online” when issuing EBT benefits as an immediate need.
Note: EWs only have read access to the [Change Status] tab on the Maintain Issuance Detail window. In the district offices, only the DOFCs and EW Supervisors have update access to this window to change the Issuance Method.
- “Activate Dormant Account” - The EW completes this section to reactivate a client’s account, when the account hasn’t been accessed for at least 180 consecutive days. The account will also go dormant if the client goes off of aid and accesses all of his/her benefits, leaving no benefits in the account. Refer to Dormant Account for more information.
Section II
The actions requested in Section II are performed by the DOFC using the EBT Administrative Terminal.
- “Personal Identification Number (PIN)” - The EW completes this section if the client wants to unlock or select/change his/her PIN.
Note: There is no functionality in CalSAWS to unlock or select/change a PIN. The PIN machine MUST be used to perform these actions.
- “Set Up Account” - The EW MUST complete this section when issuing an immediate need payment through the Administrative Terminal. Since CalSAWS does not interface with the Administrative Terminal, an account must be set up in the EBT system prior to issuing benefits. A copy of the Collect Individual Demographics Detail and Collect Individual Address Detail windows for the payee MUST be attached to this form when issuing immediate need benefits.
- “Add Emergency Cash/CalFresh Benefits” - The EW must enter the amount of cash and/or CalFresh benefits that are being authorized.
Note: If issuing the client an EBT card, the client MUST sign the SCD 2201 as proof he/she received the card. The EW Supervisor must also sign the SCD 2201.
Client Electronic Benefit Transfer (EBT) Request (SCD 2202)
Usage
The Client Electronic Benefit Transfer (EBT) Request (SCD 2202) is completed by the client when the sole request is for clerical staff to change the PIN and/or replace an EBT card.
Completion
Whenever a client comes into the District Office and requests a PIN change and/or card replacement, there is no need to involve the EW. Clerical staff must provide the client with an SCD 2202 form and either change the PIN and/or replace the card. The client must sign and date the form. The client MUST be identified per fiscal procedures. When the request is completed, the original form is to be retained for clerical records and a copy is to be scanned into Imaging.
“Returned EBT Cards to be Destroyed” (SCD 2203)
Usage
The “Returned EBT Cards to be Destroyed” (SCD 2203) form is a log used to keep track of returned EBT cards that were destroyed in the District Office or were sent to the BI Unit @ Julian to be destroyed.
Completion
The tracking is normally performed by the District Office Fiscal Clerk. Before an EBT card is destroyed or sent to the Benefit Issuance unit to be destroyed, the information about the card must be entered on the SCD 2203 log. The following procedure is to be followed:
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If the EBT card is to be destroyed... |
Then... |
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In the DO, |
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By a BI staff member at Julian, |
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Report of Electronic Theft of Benefits (EBT 2259)
Usage
The Report of Electronic Theft of Benefits (EBT 2259) must be completed by the client within 90 calendar days from the date of the electronic theft transaction in order to be eligible for a repayment. Upon receipt of a completed EBT 2259, counties have ten business days to issue repayment or replacement of benefits.
Completion
The eligibility worker may need to assist the client with completion of the form. The EBT 2259 must be filled out completely. Refer to Electronic Theft for additional information on the usage and completion of the EBT 2259 form.
EBT Scamming Acknowledgment (EBT 2259A) For Cash Benefits
Because reimbursement for electronic theft scams may only occur once in a 36-month period for cash benefits and twice in a six month period for food benefits, the client or person reporting the incident must read, initial and sign the EBT Scamming Acknowledgement EBT (2259A) form for Cash Benefits. The purpose of the EBT 2259A is to educate EBT recipients on protecting PII and reaffirming that recipients are responsible for protecting their PII.
The EBT 2259A must be reviewed with each card holder ensuring clients sign the form indicating they understand that scamming claims can only be reimbursed one-time in a 36-month period for cash benefits and twice in a six month period for food benefits. The form also states that the client understands that any delay in the submission of the EBT 2259A form may cause a delay in the processing of the benefit replacement. Refer to Electronic Theft for additional information of the EBT 2259A form.
Electronic Benefit Transfer (EBT) Request for a Designated Alternate Cardholder/Authorized Representative (CSF 64)
Usage
The Electronic Benefit Transfer (EBT) Request for a Designated Alternate Cardholder/Authorized Representative (CSF 64) is used when a client wants to request an additional cardholder to access his/her benefits.
Completion
The form can be generated through CalSAWS with the case information pre-populated in the top right corner. The client has three access options from which to select. The client may select ONLY one individual as an additional card holder per program. The additional card holder will have access to:
- CalFresh benefits,
- Cash benefits, or
- Both CalFresh and cash benefits.
The client must also have the DAC/AR sign the form and provide a photocopy of their identification. The EW MUST explain to the client that the individual selected will have complete access to benefits, and benefits that are misused or accessed without the client’s permission CANNOT be replaced. If the Primary Cardholder wishes for the AR and/or DAC to have access to the ARU, the DAC/AR must provide his/her DOB and SSN. Regulations do not require the DOB and/or SSN in order to add an DAC/AR, however the DAC/AR will not be able to utilize the ARU unless the information has been provided. Both the EW and client must sign and date the CSF 64. A copy of the completed CSF 64 form must be given to the client. The original signed CSF 64 must be scanned into the IDM system.
Reminder: Even if the DAC/AR is the second parent in the home, the second parent MUST sign the CSF 64. This is necessary for liability issues.
Refer to Automated Response Unit (ARU).
Electronic Benefit Transfer (EBT) Exemption From Cash Benefit Stagger Request (CSF 65)
Usage
The monthly issuance of cash benefits to clients within the county is staggered over a period of three calendar days (including weekends and holidays). The issuance day is determined by the last digit of the case number. When the client indicates his/her landlord or child care provider will not accept payment after the 1st of the month without imposing late fees, the client may request an exemption from the stagger cycle for cash benefits only by completing the Electronic Benefit Transfer Exemption From Cash Benefit Stagger Request (CSF 65).
Completion
The form can be generated through CalSAWS with the case information prepopulated in the top right corner. The client completes the middle section of the form indicating the reason for the exemption from cash stagger. The client has the responsibility to have his/her landlord or child care provider complete the Verification of Hardship section. Both the EW and client must sign and date the CSF 65. A copy of the completed CSF 65 form must be given to the client. The original signed CSF 65 must be scanned into Imaging.
Refer to CalFresh and Cash Stagger Issuance for more information regarding cash stagger.
Electronic Benefit Transfer (EBT) Exemption Request Form For Cash Aid (CSF 66)
Usage
State legislation allows for the delivery of cash benefits via EBT at the county’s option. State law requires that alternate methods of issuance (i.e., paper warrants) are available to those clients receiving cash assistance who demonstrate their inability to successfully use EBT. When a client requests an exemption from cash EBT, the client MUST complete an Electronic Benefit Transfer (EBT) Exemption Request Form for Cash Aid (CSF 66).
Completion
The form can be generated through CalSAWS with the case information prepopulated in the top right corner. The client completes the CSF 66 to make an official request for cash EBT exemption. The client must complete the middle section indicating the reason he/she is requesting the exemption. It is the client’s responsibility to provide proof to substantiate his/her disability. The EW must review the form with the client and both must sign and date it. The CSF 66 also requires the EW Supervisor’s signature in the County Use Section.”
The original CSF 66 is to be scanned into Imaging and a copy given to the client. Refer to Exemption from Cash EBT for more information.
Electronic Benefit Transfer (EBT) Card and Personal Identification Number (PIN) Responsibility Statement (CSF 67)
Usage
The Electronic Benefit Transfer (EBT) Card and Personal Identification Number (PIN) Responsibility Statement (CSF 67) is used to inform new EBT cardholders of how their EBT card and PIN will work and includes an explanation of the cardholders responsibilities.
Completion
The form can be generated through CalSAWS. The EW must review the CSF 67 with any cardholder being added to an existing case. Both the EW and cardholder must sign and date the CSF 67. However, a DAC/AR cardholder does NOT have to sign the CSF 67. The original copy is to be scanned into Imaging and a copy given to the cardholder.
Note: The CSF 67 is not required at intake. EBT card and PIN responsibility information is included in the CF 285 and SAWS 2 PLUS applications.
Refer to Electronic Benefit Transfer (EBT) Card and PIN Responsibility Statement” (CSF 67) for more information.
EBT Surcharge Free - Direct Deposit Handout (EBT 2216)
Usage
The EBT Surcharge Free - Direct Deposit Handout (EBT 2216) is a required handout for cash aid programs at both intake and redeterminations. The handout informs clients of the alternate methods of electronic delivery of benefits available, including EBT or direct deposit. Workers must notify clients of applicable fees, charges or surcharges associated with the EBT system, including clients who choose direct deposit to receive their cash benefits. Providing the EBT 2216 to clients meets the requirements established by the state. The EBT 2216 includes, but is not limited to, information regarding direct deposit, how to avoid ATM surcharge fees, liability for electronic theft, and how to change the method and date of benefit delivery.
California Electronic Benefit Transfer (EBT) Card (PUB 388)
Usage
The California Electronic Benefit Transfer (EBT) Card (PUB 388) is a required publication to be provided at intake and redeterminations. The publication informs clients of consumer and privacy protections and liability for theft. The PUB 388 is also available on the California EBT Client Website under EBT Brochures. The PUB 388 is also mailed to the EBT recipients by the EBT vendor with their first EBT card.
Understanding the EBT Client Website (PUB 486)
Usage
The Understanding the EBT Client Website (PUB 486) is a 16-page tutorial developed to assist EBT cardholders in navigating the EBT Client website. The PUB 486 should be provided upon request to clients interested in learning how to use the https://www.ebt.ca.gov/cardholder/.
Related Topics
Electronic Benefit Transfer (EBT) Overview