SNAP 38

Statement Regarding Food Lost in a Household Misfortune

Instructions:

If you lost food that you bought with your SNAP benefits because of a flood, fire, power outage, or other disaster, we may be able to replace your SNAP benefits.

To request replacement of SNAP benefits, you must:

Report the loss within 10 days of the food loss.
Complete this form and submit it to DCFS within 10 days after you reported the loss of food.
Provide the Dollar ($) amount of the food loss.
You must provide proof of your power loss from your utility company.

Name of Head of Household

Social Security Number

Physical Street Address

City

Parish

Phone Number

Email Address

Name of Authorized Representative

The undersigned states:

That he/she is the person named as head of household of the above-described certification, is a responsible member of the household, or is the authorized representative.
That at the time of the disaster, the head of household lived at the address shown above.
That he/she lost food bought with his/her SNAP benefits.

1. Dollar Amount of Food Purchased with SNAP Benefits Lost Due to a Disaster or Misfortune.

2. Date of the Disaster or Misfortune

3. Food purchased with SNAP benefits was lost during a household misfortune due to:

Flood

Fire

Power Outage of at Least 24 Hours

Other

4. If the answer to Question 4 is "Other," describe how the food was lost.

Digital Signatures:

I have agreed to submit the form by electronic means. By signing this form electronically, I certify that I am aware of the penalties for intentional misrepresentation of the facts including a charge of perjury for any false claim. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

By checking the box and typing my name below, I am electronically signing my form.

Digital Signature

Name of Head of Household or Responsible Household Member

Date

Name of Authorized Representative

Date