MEMORANDUM
2005 Memorandums
IM-49      05/19/05

SUBJECT:

FORM IM-110, STATEMENT OF LOSS/REPLACEMENT REQUEST, AND INSTRUCTIONS
FORM IM-113, REPLACEMENT REQUEST/AFFIDAVIT FOR FOOD STAMP BENEFITS LOST FROM EBT ACCOUNT AND INSTRUCTIONS

DISCUSSION:

Forms IM-110, Statement of Loss/Replacement Request, with instructions, and IM-113, Replacement Request/Affidavit for Food Stamp Benefits Lost from EBT Account, with instructions, are revised. The changes are as follows:

Form IM-110

Form IM-113

In the “For State Office Use” section, the following items are added:

There is no change to Item 11, Replacement Denied, other than it is moved.

The IM-110 and IM-113 forms are also available on the Intranet. To access the forms:

To access the form instructions:

When using the online version of the IM-110, make a copy for the EU, one for the case record, and send one copy to Program and Policy (Food Stamps) in State Office.

When using the online version of the IM-113, make a copy for the EU, one for the case record, and send two copies to Program and Policy (Food Stamps) in State Office.

NECESSARY ACTION:

BJK

IM-48  |   2005 Memorandums  |  IM-50