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
- In the “Identification” section, the SCN is added to the form. Staff enter both the Departmental Client Number (DCN), and the Supercase number (SCN); and
- In the “Replacement” section, a line has been added for the signature of the individual who made the replacement entry in the system.
Form IM-113
- Item 4, Supercase Number (SCN), is added;
- Item 9, Client Statement: This field replaces the Description field as it better clarifies that the EU should enter a statement as to why s/he believes the benefits were lost or stolen from the EBT account.
- Item 10, Worker Statement: The worker enters his/her statement about the situation, if applicable; and
- County Office Area Code and Phone Number: Complete this field to provide a contact number for the EU.
In the “For State Office Use” section, the following items are added:
- Remarks, and
- Items 12 through 22.
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:
- go to Family Support Division (FSD) Intranet site;
- click Food Stamps and the Food Stamp Unit page appears;
- click Forms, and under the Forms heading, select PDF Forms;
- select form IM-110 or IM-113.
To access the form instructions:
- go to Family Support Division (FSD) Intranet site;
- click Food Stamps and the Food Stamp Unit page appears;
- click Forms;
- click Forms Instructions;
- select the IM-110 or IM-113 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:
- Review this memorandum with all appropriate staff.