The IM-110 Replacement Request form is used to provide the household a method to request replacement of SNAP benefits lost from an EBT account. The form is also used to document the agency’s decision regarding the request.
This form can be completed by any adult member of a SNAP household or an authorized representative. A write-up regarding the household’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 household 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 household or an authorized representative before processing.
Ask the household what amount was lost and the circumstances surrounding the loss. If eligible for a replacement, the appropriate supervisor or manager will issue the replacement.
When benefits are replaced due to loss from an EBT account, issue the replacement benefits up to the amount of the monthly issuance. The issuance can be seen on the payment history screen in the eligibility system. 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 in the eligibility system. 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 household has the right to request a fair hearing; however, no replacement can be made while the denial is being appealed.
The original IM-110 must be scanned and indexed following local procedures to be made a part of the SNAP household’s file. The household must be notified of the decision with the IM-112 Action Taken on Your SNAP Case form. For assistance in processing a replacement, use FAMIS Resources by searching for Replacing Food Destroyed by a Household Misfortune.