Request a Replacement Common Benefit Identification Card(CBIC)

Complete the information below.  Once submitted a replacement card will be mailed to you in 4 - 6 business days.    Note: If you need a replacement card immediately,
please visit your local Department of Social Services center.

Required fields are marked with an *
* Client First Name:
 

 
* Client Last Name:
 

 
Client Social Security #: xxx-xx-xxxx
 

   
Client Phone Number: xxx-xxx-xxxx
 
           
        
* Client Date of Birth: MM/DD/YYYY
   

 
* Replacement Reason:

 
* ProgramArea: