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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES DIVISION OF BENEFIT PROGRAMS
CASE NAME
LOCALITY
CASE NUMBER
DATE
FOOD REPLACEMENT REQUEST
In order for us to consider replacing the value of your destroyed food, you must complete and return this form. You must return the completed form within 10 days of the date the food was destroyed or within 10 days of the date above.
Case Name
Address
Value of the destroyed food
Was the destroyed food bought with SNAP benefits? _____Yes _____No
When was the food destroyed or damaged?
How was food destroyed or damaged?
If your food was destroyed or damaged by a loss of electrical power, please provide the following information:
Electric Power Company: ____________________________________
Account Name: ____________________________________________
Account Number: __________________________________________
I certify that the household listed above experienced a destruction of food bought with SNAP benefits in the month of ____________________________, 20_____.
Signature
Date
The Virginia Department of Social Services is an equal opportunity provider.
032-03-0388-05-eng (7/13)