IM-113 Instructions

REPLACEMENT REQUEST/AFFIDAVIT FOR FOOD STAMP BENEFITS LOST FROM EBT ACCOUNT

PURPOSE:   (1) To provide a statement for the Eligibility Unit (EU) to certify benefits were lost from an EBT account, (2) to provide a method for the county office to request a replacement of food stamp benefits, and (3) to provide a document of authorization by the State Office Program and Policy Unit (Food Stamps) for denial or replacement of food stamp benefits.

WHEN TO USE:   Use this form when an EU reports food stamp benefits are lost from the EBT account.

NOTE: This form can be completed by a member of the food Stamp EU or the authorized representative.

MANUAL REFERENCE: Food Stamp Manual Section 1150.000.00 - 1150.005.10

NUMBER OF COPIES AND DISPOSITION:   Type or print legibly using ballpoint pen and press firmly. There are four (4) copies. The original, copy one (white), and copy two (canary) must be mailed immediately to State Office Program and Policy Unit (Food Stamps), P O Box 2320, Jefferson City, MO 65102. Give copy three, (green) to the client. Keep copy 4 (pink) and file it in the food stamp case record.

The Program and Policy Unit (Food Stamps) completes the “State Office Use” section of the form, retains the canary copy, and returns the original (white) to the county office. If using the Intranet version, complete the form and print three copies. Send one copy to the Program and Policy Unit (Food Stamps) to the address listed above, keep one copy for the file, and give one copy to the EU.

INSTRUCTIONS FOR COMPLETION

IDENTIFICATION

1. NAME: Enter the complete name of the head of the EU.
   
   
2. PAY COUNTY: Enter the identification number of the pay county.
   
   
3. DCN: Enter the 10-digit Departmental Client Number (DCN) of the head of the EU.
   
   
4. SCN: Enter the supercase number (SCN) for the EU.
   
   
5. CURRENT ADDRESS: Enter the complete current address of the EU.
   
   
6. VALUE OF BENEFITS LOST: The EU enters the value of the benefits that have been lost.
   
   
7. DATE CARD REPORTED AS LOST, STOLEN OR NOT RECEIVED: Enter the date the report was made.
   
   
8. DATE IM-113 COMPLETED: Enter the date the IM-113 is completed by the EU member or authorized representative.
   
   
9. CLIENT STATEMENT: The EU member enters his/her statement as to why or how s/he believes the benefits were lost or stolen.
   
   
10. WORKER STATEMENT: The worker enters his/her statement about the situation, if applicable. For instance, EU stated s/he reported a lost card on 12/1, but the card was not canceled until 12/15, the worker must explain what caused the delay in the card being canceled.

INFORMATION TO THE HOUSEHOLD:   The worker reviews this section with the EU prior to the EU signing the IM-113.

SIGNATURE SECTION:   After discussing the information contained in both the “Information to the EU” and the “Signature” section with the EU or the authorized representative, the individual dates and signs the form.

NOTE: The form MUST be signed by the individual or the authorized representative and the caseworker.

FOR STATE OFFICE USE

This section is completed by the Program and Policy Unit (Food Stamps) in State Office for their records, and to notify the county of the disposition of the replacement request.

11. REPLACEMENT DENIED: The reason denied is checked off and appropriate remarks are made.
    
    
12. AMOUNT REQUESTED: The amount of lost benefits for which the EU requests replacement is entered.
    
    
13. ORIGINAL AMOUNT AVAILABLE: The amount of benefits made available to the EU on the food stamp payroll (PAYHIST or FM5F) is entered.
    
    
14. ORIGINAL DATE AVAILABLE: The month/year the benefits were available to the EU is entered.
    
    
15. FULL MONTH/PARTIAL MONTH: The appropriate box is checked to indicate whether the amount available to the EU was for prorated or full month’s benefits.
    
    
16. DATE IM-113 RECEIVED IN STATE OFFICE: The date the form is received in State Office is entered in this field.
    
    
17. REPLACED BY: The name of the individual making the benefit replacement is entered.
    
    
18. AMOUNT OF BENEFITS REPLACED: The amount of benefits being replaced is entered in this field.
    
    
19. DATE REPLACED: The date the benefits were added to the EBT account is entered.
    
    
20. FOR MONTH/YEAR: The month/year in which the replacement is for is entered.
    
    
21. FULL MONTH/PARTIAL MONTH: The appropriate box for the benefits being replaced is checked.

AFTER DECISION

The county must notify the EU of the decision on the IM-112, Action on Your Food Stamp Case, advising the EU of his/her hearing rights.