The IM-110 Replacement Request form is used to provide the Eligibility Unit a method to request replacement of Food Stamp benefits lost from an EBT account. FSD staff will use this form to document the decision regarding the request.
This form can be completed by a member of the Food Stamp EU or the authorized representative. A write-up regarding the EU’s statement and any additional information received is all that is needed for benefits lost from an EBT account. Explain when the card was reported lost or stolen, the date of the loss and any additional information important in making the decision. The EU is not required to provide a police report.
The report of the loss may be made by telephone, mail, or in person however, the IM-110 Replacement Request form must be signed by a member of the Eligibility Unit or an Authorized Representative before processing.
Ask the EU what amount was lost and the circumstances surrounding the loss. If eligible for a replacement, the appropriate Eligibility Specialist Supervisor or Manager will issue the replacement.
When benefits are replaced due to loss from an EBT account, issue the replacement benefits using code RBS-BENEFITS STOLEN FROM EBT CARD up to the amount of the monthly issuance. The issuance can be seen on the Payment History (FM5F) screen in FAMIS. Make a comment regarding the date of loss, date loss is reported, date request is completed and verification used to determine replacement.
When a request to replace benefits is denied make a comment on the EUMEMROL screen. The comment should state the date of loss, date loss is reported, date request is completed and the reason for the denial. If a replacement is totally or partially denied the EU has the right to request a fair hearing. However, no replacement can be made while the denial is being appealed.
For replacement decisions made and entered by FSD staff, the original IM-110 must be scanned and indexed following local procedures.
FSD staff notifies the EU of the decision on the IM-112 Action Taken on Your Food Stamp Case form. For assistance in processing a replacement, refer to user guide FOOD STAMP REPLACEMENT.