Information about you

Client's name(Required)
Please enter your name here.
Please enter your Agency ID (APID) which can be found on DTA notices, or on DTAConnect
Address(Required)

Information about your stolen benefits

Please enter the date when you noticed that your benefits were stolen(Required)
Date stolen SNAP benefits were used
Date stolen TAFDC benefits were used
Date stolen EAEDC benefits were used
For example, where the stolen benefits were used or where you last used your card

Please carefully review the following statements before signing below.

I understand that:

  • I have a 30-day window from the date I discovered my SNAP benefits were stolen to submit a claim for replacement.
  • The maximum amount of SNAP replacement benefits I can receive due to theft is either two months of SNAP benefits or the actual reported loss, whichever is lower.
  • I am eligible for SNAP replacement benefits due to theft only twice within a federal fiscal year, which runs from October 1 to September 30.
  • Making a false or misleading statement on this form on purpose could be a crime (perjury) or an Intentional Program Violation (IPV).
  • If I disagree with DTA's decision about my claim for replacement benefits, I have the right to a Fair Hearing.
  • By typing your full name and selecting the "Submit your claim" button below, you are signing this form electronically.  You agree your electronic signature is the legal equivalent of your manual signature. You acknowledge receipt and understanding of the above policies.

Signature
Date