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FOOD STAMP HANDBOOK §3:1230 (Cont) FORMS AND INSTRUCTIONS Handbook

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

DFA 303 (1/83) Part A — Household Affidavit

Before the household or an authorized representative completes this section, enter the address where the household should return the original ATP/food coupon book(s) shouid they receive it.

When signed, review this section for completeness, paying particular attention to the following items:

- When a claimant indicates the reason for repiacement is a stolen or destroyed ATP or destroyed food coupon book(s) or food, be sure the claimant also indicates the date stolen or destroyed, how destroyed and the amount destroyed,

- Be sure that the claimant signs and dates the affidavit,

NOTE: A request for replacement must be acted upon within ten days of the household's request, either by issuing a replacement, or denying the request.

Part B — Verification Enter the following information as applicable for the type of request:

- Date the original ATP/food coupon book(s) was issued. - Serial number of the original ATP.

~ Amount of the original ATP/food coupon allotment.

- Date replacement is requested.

NOTE: If the request for replacement is for a destroyed ATP, food coupon book(s) or food, enter the type of household disaster and the source of verification.

As appropriate for each type of replacement be certain to verify that:

The ATP/food coupon book(s) to be replaced was actually issued.

The ATP/food coupon book(s) to be replaced was not returned as undeliverable.

The request for replacement was reported within the time frames provided by regulation.

The disaster occurred and meets the definition of a household disaster.

The household has not already received the allowable number of replacements during the most recent six-month period, which includes the current month. There ara no limitations on the number of replacements for food destroyed in a household disaster.

f. The replacement is otherwise appropriate as defined by regulation.

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CALIFORNIA-DSS-MANUAL-SS Rev. 1376 replaces issue 2202 Effective 2/15/84

(MANUAL LETTER NO. 84-13) fo fs ¥