Form H1175 "Ebt Change Request" - Texas

What Is Form H1175?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form H1175 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form H1175 "Ebt Change Request" - Texas

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Form H1175
December 2020-E
EBT Change Request
Part I — Send SNAP Priority Benefit Record
SNAP EDG No.
Primary Cardholder Name — Last, First, Middle (22 characters maximum)
(For combined allotments, complete both
First Month and Second Month lines.)
First Month
No. in Household
Benefit Month
Allotment Value
County No.
Type
Expedited
Timely
Form H1855 signed?
Yes
No
Second Month
No. in Household
Benefit Month
Allotment Value
County No.
Type
Timely
Form H1855 signed?
Yes
No
TIERS inquiry completed?
Yes
No
Reason
Worked Manually/TIERS Unavailable
Other (specify):
Supervisor's Review
Application and supporting documents reviewed? ..................................................
Yes
No
Date
Employee No.
Supervisor's Initials
Part II — Update Primary Cardholder Record
Complete this section to make changes to the primary cardholder record when those changes cannot be made in the EBT system by TIERS.
Primary Cardholder Name - Last, First, Middle (22 characters maximum)
TANF EDG No.
SNAP EDG No.
Update the primary cardholder record as follows:
Primary Cardholder Name - Last, First, Middle (22 characters maximum)
Date of Birth (mmddyyyy)
Gender
Social Security No.
M
F
Mailing Address — Street or P.O. Box (if addresses are different, use TANF address)
Mailing Address — Second Line
City
County
State
ZIP Code
HOH?
EDG Name
Endorsement
Yes
No
Yes
No
Part III — Split Primary Cardholder Records
Complete Part III if accounts are currently linked and need to be separated.
EDG Name
EDG No.
EDG No.
Part IV — Merge Primary Cardholder Records
Complete Part IV only after ensuring the cardholder records match on name, date of birth, sex and SSN in TIERS.
EDG Name
EDG No.
EDG No.
Signature — Requestor (Advisor)
Date
Employee No.
Signature — Person Completing Request
Date
Employee No.
Form H1175
December 2020-E
EBT Change Request
Part I — Send SNAP Priority Benefit Record
SNAP EDG No.
Primary Cardholder Name — Last, First, Middle (22 characters maximum)
(For combined allotments, complete both
First Month and Second Month lines.)
First Month
No. in Household
Benefit Month
Allotment Value
County No.
Type
Expedited
Timely
Form H1855 signed?
Yes
No
Second Month
No. in Household
Benefit Month
Allotment Value
County No.
Type
Timely
Form H1855 signed?
Yes
No
TIERS inquiry completed?
Yes
No
Reason
Worked Manually/TIERS Unavailable
Other (specify):
Supervisor's Review
Application and supporting documents reviewed? ..................................................
Yes
No
Date
Employee No.
Supervisor's Initials
Part II — Update Primary Cardholder Record
Complete this section to make changes to the primary cardholder record when those changes cannot be made in the EBT system by TIERS.
Primary Cardholder Name - Last, First, Middle (22 characters maximum)
TANF EDG No.
SNAP EDG No.
Update the primary cardholder record as follows:
Primary Cardholder Name - Last, First, Middle (22 characters maximum)
Date of Birth (mmddyyyy)
Gender
Social Security No.
M
F
Mailing Address — Street or P.O. Box (if addresses are different, use TANF address)
Mailing Address — Second Line
City
County
State
ZIP Code
HOH?
EDG Name
Endorsement
Yes
No
Yes
No
Part III — Split Primary Cardholder Records
Complete Part III if accounts are currently linked and need to be separated.
EDG Name
EDG No.
EDG No.
Part IV — Merge Primary Cardholder Records
Complete Part IV only after ensuring the cardholder records match on name, date of birth, sex and SSN in TIERS.
EDG Name
EDG No.
EDG No.
Signature — Requestor (Advisor)
Date
Employee No.
Signature — Person Completing Request
Date
Employee No.