Temp 2201 Form PDF Details

In today's fast-paced world, overseeing one's financial and food assistance benefits can sometimes require the help of a trusted individual, especially for those navigating the complexities of life's many challenges. Recognizing this, the State of California's Health and Human Services Agency, through the California Department of Social Services, provides an essential form, the Temp 2201. This crucial document serves as a lifeline for those needing to appoint a Designated Alternate Card Holder/Authorized Representative for their Cash Aid/Food Stamp Electronic Benefit Transfer (EBT) accounts. It's a straightforward process designed to safeguard beneficiaries' interests while facilitating access to necessary financial and nutrition assistance. Applicants are prompted to disclose the name and birthdate of the person they trust to manage their EBT benefits, signifying the immense trust placed in the chosen individual. The form distinguishes between new appointments, changes, or removals of a Designated Alternate Card Holder/Authorized Representative, ensuring beneficiaries have full control over who can access their benefits. Moreover, it underscores the importance of understanding that once someone is designated, they gain full access to the EBT benefits, emphasizing the need for a careful selection process. Additionally, it reminds beneficiaries of their responsibility to report a lost or stolen card immediately and to notify their county worker if they decide to change the person managing their benefits. The Temp 2201 form, thus, acts not just as a document but as a bridge connecting those in need with their support systems, ensuring they do not have to face the challenge of managing their benefits alone.

QuestionAnswer
Form NameTemp 2201 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestemp 2201 english, EBT, CERTIFICATION, temp 2201

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CASH AID/FOOD STAMP ELECTRONIC BENEFIT TRANSFER - EBT

REQUEST FOR A DESIGNATED ALTERNATE CARD HOLDER/AUTHORIZED REPRESENTATIVE

CASE NAME:

WORKER NAME

CASE NUMBER:

DATE:

INSTRUCTIONS:

A Designated Alternate Card Holder/Authorized Representative is a responsible person that you trust. A Designated Alternate Card Holder/Authorized Representative will have an EBT card issued in their name and the card holder/authorized representative, you choose will have access to all your cash aid or food stamp EBT.

●Tell us the name and birthdate of the person you want to be a Designated Alternate Card Holder/Authorized Representative

●Sign and complete this form

●Send or bring in the form to your County Office

■

Designated Alternate Card Holder

■ Authorized Representative

■

New

■ Change

■ Remove

NAME OF REQUESTED DESIGNATED ALTERNATE CARDHOLDER/AUTHORIZED REPRESENTATIVE

BIRTHDATE

CERTIFICATION:

I understand the person I make Designated Alternate Card Holder/Authorized Representative will have access to ALL of my cash aid and/or food stamp EBT. The County is not responsible for lost or stolen benefits. I can change who can access my cash aid or food stamps by calling my County Worker.

SIGNATURE

PHONE

DATE

To be signed by Designated Alternate Card Holder/Authorized Representative

I agree to be a Designated Alternate Card Holder/Authorized Representative. By using this card, I agree to the terms of the cash aid/food stamp Electronic Benefit Transfer - EBT program.

DESIGNATED ALTERNATE CARD HOLDER/AUTHORIZED REPRESENTATIVE SIGNATURE

DATE

Report lost or stolen card IMMEDIATELY by calling toll free 1-877-328-9677.

REMINDER

It is YOUR responsibility to call the toll-free customer service telephone number (1-877-328-9677) to terminate another household member’s, Designated Alternate Cardholder’s, or Authorized Representative’s access to your EBT account.

TEMP 2201 (7/02) REQUIRED FORM - SUBSTITUTE PERMITTED

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This PDF doc needs some specific details; in order to guarantee accuracy, take the time to consider the recommendations just below:

1. The temp 2201 form necessitates certain details to be typed in. Be sure the following blanks are filled out:

CARDHOLDER conclusion process explained (step 1)

2. Once this part is done, proceed to type in the relevant details in these: SIGNATURE, PHONE, DATE, To be signed by Designated, I agree to be a Designated, DESIGNATED ALTERNATE CARD, DATE, Report lost or stolen card, and REMINDER It is YOUR responsibility.

SIGNATURE, DESIGNATED ALTERNATE CARD, and REMINDER It is YOUR responsibility inside CARDHOLDER

Always be really mindful while filling out SIGNATURE and DESIGNATED ALTERNATE CARD, because this is the part where most users make some mistakes.

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