Page 569

VIRGINIA DEPARTMENT OF SOCIAL SERVICES FOOD REQUEST REPLACEMENT

10/24 VOLUME V, PART XXIV, PAGE 74

Food Replacement Request

FORM NUMBER - 032-03-0388

PURPOSE OF FORM - This form will allow the local agency determine the value of food destroyed so that the agency 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 SNAP 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 the replacement of food destroyed. A household member must sign and date the form.

TRANSMITTAL #35