Form Ebt 10 PDF Details

One of the most common forms that is used to report wage and hour violations is Form Ebt 10. This form is used by employees to document any time they have worked, as well as any overtime hours they have worked. It is important to understand how to fill out this form correctly, so that any potential wage and hour violations can be properly documented. In this blog post, we will teach you how to properly fill out a Form Ebt 10. By following these instructions, you can make sure that your form is accurate and complete, which will help protect your rights if there are any violations.

QuestionAnswer
Form NameForm Ebt 10
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names ebt ri form

Form Preview Example

 

 

 

STATE OF RHODE ISLAND

 

 

 

EBT-10

 

 

 

DEPARTMENT OF HUMAN SERVICES

Rev: 03/13

 

 

 

 

 

Request for RI EBT Card

 

 

 

 

 

 

 

 

 

 

 

 

DATE RECEIVED:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE LOCATION (CHECK ONE):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

฀ Providence

฀ Pawtucket ฀ Warwick

฀ Woonsocket

฀ Newport

 

 

 

 

 

 

฀ South County

 

 

 

 

Last Four Digits of SSN: ___ ___ ___ ___

DHS ID #: ______________ Date of Birth: ______ / ______ / ______

 

 

 

 

(IF KNOWN)

 

 

 

MM DD

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

First Name

 

 

 

 

 

MI

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

Apt. #

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

Zip Code

 

 

Phone Number

 

 

 

 

Check this box if this is a new address.

MAILING ADDRESS (IF DIFFERENT)

Street

Is this the address where would like your card mailed? Yes No

Apt. #

City/Town

State

Zip Code

 

 

 

Is this the address where you would like your card mailed?

Yes

No

Why you are requesting a new EBT card?

 The card does not work

The card was stolen

The card is lost

The card was destroyed

I do not have access to the card

Other: __________________________________________

__________________________________________

__________________________________________________________

___________________

Signature

Date

Write in this section only if you are an Authorized Representative and/or an Authorized Payee:

Authorized Representative

Authorized Payee

Both Authorized Representative & Payee

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

First Name

 

 

MI

Date of Birth ______ / ______ /

_________

 

 

Last Four Digits of SSN: ___ ___ ___ ___

MM

DD

 

YYYY

 

 

 

 

 

_________________________________________________________

___________________

 

Signature

 

 

 

 

 

 

 

Date

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