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Ohio Department of Job and Family Services

STATEMENT REQUESTING REPLACEMENT OF SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) BENEFITS

Name

Address

City, State, Zip Code

Phone Number

Date of Loss

Case Number or Social Security Number

FOR CDJFS USE ONLY

Date form was received from the assistance group

Reason for the request

I am requesting the replacement of $ of food which were destroyed in a disaster or misfortune. (Explain how the destruction occurred in the REMARKS section below. Verification of the disaster or misfortune will be required.)

Request for other reason(s). Be specific.

REMARKS (To be completed by the assistance group member to explain how the loss occurred, attach any verification of the loss that you may have).

CAREFULLY READ AND SIGN

I acknowledge that if this statement is not signed and returned to the county agency within 10 days of the date the loss was reported, the county agency shall not replace the SNAP benefits. I certify that I am aware that there are penalties for intentional misrepresentation of facts, including but not limited to perjury for a false claim. I understand that the agency has 10 days from the date I reported this loss or two working days from when I signed and returned this form, whichever is later, to issue any replacement due me unless my request is delayed or denied.

Signature

Date

If you do not agree with the action taken on your case, you may request a fair hearing orally or in writing.

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Your Civil Rights:

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html (opens in a new window on an external site), and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)fax: (202) 690-7442; or
(3)email: program.intake@usda.gov.

This institution is an equal opportunity provider.

JFS 07222 (Rev. 10/2016)Page 2 of 2