Page 65
"FOOD STAMP HANDBOOK
‘Handbook FORMS AND INSTRUCTIONS
__ 83-1230 (Cont.}|
63-1230 STATE FORMS & INSTRUCTIONS (Continued)
63-1230 DFA 303 (1/83)
STATE OF CALIFORNIA AEaLIn ant
COUNTY USE ONLY
DEPARTMENT OF SOCIML SERVICES
rents
REPLACEMENT AFFIDAVIT/AUTHORIZATION
CASE onthe
ORKER
TYPE OF LOSS D are
© Food Coupon Beokis)
O Food
PART A. HOUSEHOLD AFFIDAVIT
, the undersigned, living at
rr
im Did not receive in the mail the ATP/Food Coupon Baokis} af
. California, dectare that the household named above:
ISTREET ADDRESS)
ron
(7) received an ATP for the period of
Oo Stolen: Date stolen O Destoyed: How?,
O Received Food Coupon Bookis} for the period of
How?
Date destroyed
California, for the period of
» however it was:
Date destroyed
, however, they were destroyed.
“TSTREET ADDRESS
Amount §,
0 Purchased food with Food Coupon Book{s}, but the food was destroyad.
How?
Date destroyed
Amaunt §.
(declare that the foregoing is true and cerract to
imprisoned or beth,
| further declare that if at any time { receive the above describad ATP/Foad Coupon Book(s}, it will be returned to:
the best of my knowledge. intentionally withhold information or give false information | may be denied participation in the Food Stamp Program: fined
i also understand that # 1
BIGWATURE OF CLAIMANT
ad
Date
PART B - VERIFICATION
DATE ATR COUPONS ISSUED ‘ATP SERIAL © VALUE OF ATP-FUOD COUPON ALLOTMENT
‘DATE REPLACEMENT REQUESTED
Type of housshold disaster: Source of verification:
Has household received any repiacemants during the last five manths? © Yes O No If Yes, how many? Type of replacementis}: 1. 2. 3. 4. PART C - REPLACEMENT AUTHORIZATION Request: © Approved 0 Denied Reason for denial THOUNT 10 8 REMACED TAME BF PERSON ALTHORTING, DENYING REQUEST ‘ReveweD a are 4 PART D - HOUSEHOLD ACKNOWLEDGEMENT OF RECEIPT { acknowledge the receipt of a replacement: (Check appropriate box} a ATP im Food Coupon Bookis} Seriat Number In the amount of 8 REPLACEMENT AECEWED WY CLAIMANT'S SIGNATUREL preg DPA TD} -1 BB+ Bmayuen boners Bush .. CALIFORNIA-DSS-MANUAL-SS Rev. 1374 replaces Issue 2200 Effective 2/15/84
(MANUAL LETTER NO. 84-13) (OG