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1 | P a g e Request for Replacement of Stolen SNAP Benefits Request for Replacement of Stolen Supplemental Nutrition Assistance Program (SNAP ) Benefits Si tienen dificultad en entender este documento favor de comunicarse , con la oficina de distrito para asistencia Si W gen difikilte poow konprann dokiman sa a. Tanpi kontakte biwo distri a pou `ed. You may use this form to request the replacement of SNAP benefits which were stolen electronically through skimming, cloning, phishing, or other similar fraudulent methods. You must take the necessary steps to report specific information regarding fraudulent transactions. You can locate this information by: Checking your EBT history at https://ebtedge.com/ or by downloading the EBT Edge app (available for download in the Apple App Store and Google Play Store); or Calling the toll-free EBT Customer Service line at 1-866-884-2868; you may also use the helpline to: Listen to your last ten transactions on the automated menu. Please note, if you have not taken the following measures: 1. Reported your EBT card lost or stolen 2. Have not yet requested a new EBT card, due to your benefits being stolen. Unfortunately, your SNAP account is more than likely still at risk. 3. No replacement benefits may be issued until you have reported your compromised EBT card lost or stolen, request a new card and change your PIN. 4. Please call EBT Customer Service at 1-866-884-2868 or go to www.ebtedge.com . Please Confirm: The compromised EBT card was cancelled. ( ) Yes ( ) No You can submit your Request for Replacement of Stolen Supplemental Nutrition Assistance Program benefits by any of the following methods: In person, email, or via United States Postal Service. ST. CROIX, VI Department of Human Services Issuance Unit 4102 Mars Hill Frederiksted, VI 00840-3376 Ph. (340) 772-7100, Ext. 7103, Email: certoffice.stx@dhs.iv.gov ST. THOMAS/WATER ISLAND, VI Department of Human Services Issuance Unit 1303 Hospital Ground, Ste. 1 St. Thomas, VI 00802-6722 Ph. (340) 774-0930 or (340) 774-2399 Email: certoffice.stt@dhs.vi.gov ST. JOHN, VI DHS, Issuance Unit Multi-Purpose Building, 300 Enighed and Contant Cruz Bay, St. John Phone: 340-776-6334 MAILING: Please use the St. Thomas mailing address 2 | P a g e Request for Replacement of Stolen SNAP Benefits HOUSEHOLD INFORMATION Case Number :__________________________ Case Name_______________________________________________________________________ Last 4 digits of Electronic Benefit Transfer (EBT) card number:______________________________ Mailing Address : ______________________________________________ Apt./Suite:________________________________________ City ______________________________________ State____________ Zip Code__________ BENEFIT THEFT INFORMATION I, ___________________________________________________________, am the head of household or the Households Authorized Representative for the above- named case and wish to report fraudulent transaction(s) on the EBT card number listed above . 1. Do you believe that your EBT benefits were stolen? ( ) Yes ( ) No 2. Was your EBT Card lost or stolen? ( )Lost ( ) Stolen 3. Date your card was lost or stolen? ____________________ 4. When was the last time you used your EBT card? _________________ 5. Total SNAP benefits which were stolen? ________________________ 3 | P a g e Request for Replacement of Stolen SNAP Benefits FRAUDULENT TRANSACTIONS List each fraudulent transaction individually using a separate line for each transaction, even for purchases occurring on the same date or at the same retailer. These transactions should total up to the total amount of stolen benefits you reported on page #3. Please list fraudulent transaction (s) Date Of Transaction Fraudulent Transaction Amount Retailer Name & Location (City and State) of Transaction Attach a separate sheet if additional space is needed. Please provide any additional information about the theft you feel is important for us to know 4 | P a g e Request for Replacement of Stolen SNAP Benefits CERTIFICATION DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE STATEMENTS BELOW I understand and agree to the following: I must complete, sign, and submit this form to request the replacement of stolen SNAP benefits. The submission of this request does not guarantee that my benefit will be replaced. I have a right to a fair hearing to contest the denial or delay of replacement issuance, Replacement would not be issued pending the fair hearing decision. If I have knowingly given incorrect information about the facts stated on this application, I may be charged with intentional Program Violation (IPV) and may be subject to civil and criminal penalties including, but not limited to, perjury for a false claim. ____________________________________________ Name (Please Print) ____________________________________________ ___________________ Signature Date Please check off your relation to household ( ) Head of Household ( ) Household’s Authorized Representative