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For Local Department Use: Case Number FS Case Name Date Locality Address City, State, Zip Food Replacement Request How was food destroyed or damaged? Value of destroyed food: I hereby certify, under penalty of perjury, that the household listed above has experienced the destruction of food, in the month of _______________________, 20__. Signature Date Instructions for completing Replacement of Lost Food Affidavit PURPOSE AND USE OF FORM– This form allows the localagency to assess the value of food destroyed. Depending on the reason for the loss, the local department may provide additional SNAP benefits to cover the value of food destroyed. USE OF FORM– The agency must provide the form tohouseholds that report a household disaster that resulted in the loss of food purchased with Supplemental Nutrition Assistance Program benefits. NUMBER OF COPIES– Two. DISPOSITION OF FORM– The local agency must providea copy of the completed form to the household and file a copy in the case record. INSTRUCTIONS FOR PREPARATION OF FORM– Local agencystaff should complete the identifying case information at the top of the form. A household member or an authorized representative must complete or provide information for the bottom section regarding food destroyed. A household member must sign and date the form. REVISED FEBRUARY 2023