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FOOD STAMP HANDBOOK Handbook ___FORMS AND INSTRUCTIONS ___ 63-1230 (Cont,

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 303 (1/83)

Form instructions (For CWD)

REPLACEMENT AFFIDAVIT/ AUTHORIZATION

Purpose:

The DFA 303 is a form completed by the household or an authorized representative and the . county. This form is used to (1) initiate a request for a replacement ATP/food coupon book(s}, (2) verify that replacement of an ATP/food coupon book(s) is appropriate, and (3) acknowledge receipt of a replacement ATP/food coupon book(s).

Part A is completed by the household or an authorized representative and is the household’s affidavit indicating the reason for the replacement.

Part B is completed by the county and is used to verify that the request for replacement is appropriate. This section also provides identifying information relating to the original ATP/food coupon book(s) that was issued.

Part C is completed by the county and is used to authorize the replacement and the amount to be replaced, or to deny the replacement.

Part D is completed in part by the county and signed by the claimant to acknowledge receipt of the replacement ATP/food coupon book(s) issued to the household.

Preparation: , The household must come into the county office to sign the affidavit, in! most instances. However, the affidavit must be mailed to the household if the household is unable to come

into the office because of age, handicap or distance from the office and is unable to appoint an authorized representative.

Complete an original and one copy if the individual is requesting the replacement in person. Compiete a second copy for pending if the form will be mailed for completion. (Additional copies

may be required by the county’s internal system.) Enter the following identifying information in the county-use section.

- Case Name - Case Number - Worker

Check the applicable box for the type of loss being reported,

CALIFORNIA-DSS-MANUAL-SS Rev. 1375 replaces issue 2201 Effective 2/15/84