Affidavit for Nonreceipt or Destroyed Food Stamp Benefits



Affidavit for Nonreceipt or Destroyed Food Stamp BenefitsForm H1855April 2003-EFood Stamp Case No. FORMTEXT ?????Certifying Office FORMTEXT ?????Case Name FORMTEXT ?????Date Reported FORMTEXT ?????Date Received FORMTEXT ?????Address Field FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????ZIP Code FORMTEXT ?????? Benefits Issued via Administrative Terminal Application (ATA)My household has not been issued and has not received food stamp benefits for the month of FORMTEXT ?????, FORMTEXT ????? (year).? Replacement BenefitsOld Address (if applicable) FORMTEXT ?????Benefit Month/Year FORMTEXT ?????Allotment Amount FORMTEXT ?????Original Issuance No. FORMTEXT ?????Original Issue Date FORMTEXT ?????Some of my household's food bought with food stamp benefits was destroyed in a household disaster on FORMTEXT ?????.The amount destroyed was FORMTEXT ?????.If this affidavit is not signed and received by the local office within 10 days of the date of the report, no replacement will be made.I certify that the statement checked above is true and correct. I understand that anyone who obtains or uses food stamp benefits for which he is not eligible can be charged with a criminal offense. If convicted, he may be fined, imprisoned, or both.6032515049500Signature — Head of Household or Responsible Family Member FORMTEXT ?????6223015049500Date ................
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