Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune
Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune Instructions: If you lost food that you bought with your SNAP benefits because of a fire, flood, loss of electricity, broken refrigerator/freezer, or other disaster, we may be able to replace your SNAP benefits. The most we can replace is one month of benefits. To request replacement: • You must report the loss within 10 days of the food loss. You can do this by phone or in writing. • Complete the request form and submit it to the district office within 10 days after you reported the loss of food. • You can mail. email or fax the form using the agency contact information listed below. • DHS will attempt to confirm what happened by contacting a third party. If DHS is unable to verify what happened, you will need to submit documentation verifying the loss of food. DHS will issue replacement SNAP benefits if you are eligible. . Non-Discrimination Statement In accordance with federal civil rights law and U.S. …
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Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune Instructions: If you lost food that you bought with your SNAP benefits because of a fire, flood, loss of electricity, broken refrigerator/freezer, or other disaster, we may be able to replace your SNAP benefits. The most we can replace is one month of benefits. To request replacement: • You must report the loss within 10 days of the food loss. You can do this by phone or in writing. • Complete the request form and submit it to the district office within 10 days after you reported the loss of food. • You can mail. email or fax the form using the agency contact information listed below. • DHS will attempt to confirm what happened by contacting a third party. If DHS is unable to verify what happened, you will need to submit documentation verifying the loss of food. DHS will issue replacement SNAP benefits if you are eligible. . Non-Discrimination Statement In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. ST. CROIX, VI Department of Human Services Certification Office 4102 Mars Hill Frederiksted, VI 00840-3376 Ph. (340) 772-7100, Ext. 7159/7192, (340) 772-7120 E-Mail: certoffice.stx@dhs.vi.gov ST. THOMAS/WATER ISLAND, VI Department of Human Services Certification Office 1303 Hospital Ground, Ste. 1 St. Thomas, VI 00802-6722 Ph. (340) 774-0930 or (340) 774-2399 E-Mail: certoffice.stt@dhs.vi.gov ST. JOHN, VI Multi-Purpose Building, 300 Enighed and Contant Cruz Bay, St. John Email: certoffice.stt@dhs.vi.gov Phone: 340-776-6334 MAILING: Please use the St. Thomas mailing address GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services DIVISION OF FAMILY ASSISTANCE Non-Discrimination Statement In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune ___________________________________________________ ______________________ Case name Case Number _______________________________________________________ ________________________ Home Address Contact Number _________________________________________________________________________________________ Mailing Address I lost food bought with my SNAP benefits worth $_________________ due to a household disaster or misfortune that happened on ________/___________ / _____________. month day year I lost my food on ______________/ __________/____________ month day year The household disaster/misfortune was: _________________________________________________________________________________________ _________________________________________________________________________________________ Certification The information I gave is true to the best of my knowledge. I understand that making a false or misleading statement on this form on purpose could be a crime (perjury) or an Intentional Program Violation (IPV). A person found to have committed an IPV will be ineligible for SNAP benefits for 1 year for the first IPV, 2 years for the second IPV, and permanently for the third IPV. I understand I have the right to a fair hearing to contest the denial or delay of a replacement issuance for my household. Replacements would not be issued pending the fair hearing decision. Print Name ___________________________________ Signature _____________________________________ Date _____________________________ Relation to Household: ( ) Head of Household ( ) Household Member ( ) Authorized Representative GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services DIVISION OF FAMILY ASSISTANCE