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63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 DFA 303 (1/83) Part C — Replacement Authorization

- Check the applicable box to indicate the disposition of the request. - ff the request is denied, give the reason for denial.

NOTE: If the household's request for replacement is being denied, the household must be provided with a DFA 377.4,

+ Enter total amount of ATP/food coupons to be replaced. - Enter signature of person authorizing or denying request, - Enter signature of individual reviewing request, if any.

- Enter date request is approved or denied.

Part D — Household Acknowledgement of Receipt

Before this section is signed by the claimant, enter one of the following as applicable to the

replacement: (1) the serial number of the replacement ATP, or (2) the amount of the replacement food coupon book(s).

The claimant must check the appropriate box for an ATP or food coupon book(s} and sign and date

this section when the replacement is issued, Hf, however, the claimant refuses to sign this section, the replacement cannot be denied,

!f the ATP or food coupon book(s) is to be mailed, the original DFA 303 and one copy should be enclosed with the ATP/food coupon book(s) and a self-addressed envelope for returning after it is signed by the household. The county must retain a copy of the DFA 303 pending the return of the original. The county must establish a system of follow-up to ensure that the original is returned.

Be sure this section is signed and dated, and the appropriate box is checked.

Distribution:

The original is filed in the case file, and one copy is provided to the household.