| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | FORM IM-110, STATEMENT OF LOSS/REPLACEMENT REQUEST, AND INSTRUCTIONS |
DISCUSSION:
At the suggestion of field staff, the Statement of Loss/Replacement Request (IM-110) and instructions are revised to include the social security number and date of birth of the head of the EU, and load number of the eligibility specialist.
The REASON FOR LOSS section is changed to clarify that the request is for food purchased with food stamp benefits as described in Food Stamp Manual section 1150.010.00 FOOD PURCHASED WITH FOOD STAMP BENEFITS LOST IN AN EU MISFORTUNE.
The IM-110 form and instructions are available on the Intranet. Use the PDF version, WORD version, or carbonless tri-copy form.
To access the PDF version and/or instructions,
- go to Family Support Division (FSD) Intranet site,
- select Food Stamps,
- under Forms select Forms Manual from the drop-down list,
- select Volume 2, and
- select PDF IM-110
or instructions.
To complete the WORD version,
- go to D:\FSFORMS and
- select the IM-110.
The carbonless IM-110 may be ordered from the warehouse using normal ordering procedures. Use the current IM-110 to depletion.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.