MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION REPLACEMENT REQUEST	DATE REQUEST RECEIVED BY THE FAMILY SUPPORT DIVISION
THIS ELIGIBILITY UNIT REPORTS: Food I purchased with Food Stamp benefits was destroyed in a household misfortune. My Missouri EBT card is lost, stolen, or not received, and Food Stamp benefits were used without my permission. Food Stamp benefits were removed from my EBT account through a manual voucher transaction without my permission. If loss is not reported within ten days of the loss, or this statement is not signed and returned within ten days of the date the loss is reported, no replacement will be made.
IDENTIFICATION
NAME	RESIDENCE COUNTY	DCN
CURRENT ADDRESS	SOCIAL SECURITY NUMBER	DATE OF BIRTH
AMOUNT OF LOSS	DATE OF LOSS	DATE LOSS REPORTED TO FSD	DATE REPLACEMENT REQUEST FORM COMPLETED
CUSTOMER STATEMENT / REASON FOR LOSS
VERIFICATION OF LOSS (COMPLETED BY FAMILY SUPPORT DIVISION)
TO THE HOUSEHOLD
FOR ALL REPLACEMENT REQUESTS OF FOOD STAMP BENEFITS LOST FROM THE EBT CARD: If the above benefits were used by anyone residing or visiting in your household or by your authorized representative, no replacement will be made. If benefits are lost prior to a report of a lost or stolen Missouri EBT card, unless lost prior to receipt of the card by the household, a replacement will not be made. If someone accesses benefits without permission from the household, a replacement will not be made unless benefits are accessed after the report of a lost or stolen card.
SIGNATURE SECTION
I hereby certify, under penalty of perjury and/or fraud, that I have lost food purchased with Food Stamp benefits, or that Food Stamp benefits were removed from my EBT card without my permission. I understand that if I make fraudulent statements about my loss of food or benefits, I may be ineligible to continue in the Food Stamp Program and may be liable to prosecution under both Federal and State laws.
DATE	SIGNATURE OF PERSON REQUESTING REPLACEMENT ►
DATE	SIGNATURE (FSD STAFF) ►
REPLACEMENT DETERMINATION
Replacement Approved Replacement Denied (reason): Documentation not received. Not reported within 10 days of loss. Signed form not received in county office within 10 days of report. Original benefits used by EU or Authorized Representative	Benefits lost prior to report of lost/stolen card, and not lost prior to receipt of card by EU. Report of lost/stolen card not made. Manual voucher completed by member of the EU or Auth. Rep. Other: __________________________________________________ __________________________________________________
Signature (FSD Staff)	Title and Date
REPLACEMENT APPROVED – COMPLETED BY FSD
AMOUNT REQUESTED	AMOUNT REPLACED	DATE ENTERED INTO SYSTEM

MO 88-0404 (07-14)	IM-110 (07-14)

RETAIN 36 MONTHS