Some offices closed Oct. 2 due to power outages

Food Loss Replacement Request - Form 841

Name

First

Middle initial

Last

County (required)

Residential Address

Address

Address 2

City/Town

State

ZIP/Postal Code

Client ID number

Case number

Phone number

Email address

My household has lost food in the amount of:

I used my EBT card (Supplemental Nutrition Assistance Program) to buy food that was spoiled or lost because of a power outage of four or more hours or other property damage during the disaster.

I hereby certify, under penalty of perjury, that my household suffered food loss because of a disaster on:

Electronic signature

By selecting this button and typing my name below, I am electronically signing my food loss form.

Name

First

Middle initial

Last