PURPOSE AND USE OF FORM – This form allows the local agency 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 to households 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 provide a copy of the completed form to the household and file a copy in the case record.

INSTRUCTIONS FOR PREPARATION OF FORM – Local agency staff 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.