MEMORANDUM

DISCUSSION:

This memorandum introduces a revised IM-110 Replacement Request form, discusses policy and procedures for requesting a replacement of Food Stamp benefits, and addresses questions that have been raised by staff regarding replacements.

New IM-110 Replacement Request form

The Statement of Loss/Replacement Request (IM-110) and Replacement/Affidavit for Food Stamp Benefits Lost from an EBT Account (IM-113) have been combined. The new IM-110 form has been renamed Replacement Request, and includes the following changes:

• Check boxes have been added to the top of the form to select the type of loss.
• Two date boxes have been added to the top of the form, DATE RECEIVED IN COUNTY OFFICE and DATE RECEIVED IN STATE OFFICE.
• DATE OF LOSS box has been added, to more clearly identify the exact date of loss for reporting timeframes. This should be the date the loss occurred.
• The SIGNATURE section is changed to state that the request is for food purchased with Food Stamp benefits or Food Stamp benefits removed from an EBT account without the authorization of the EU.
• REPLACEMENT DETERMINATION section has been added including check boxes for approval, and the most common reasons for request denials.

This form can be completed by a member of the Food Stamp EU or the authorized representative.

EU's Statement of Loss

The report of loss may be made by telephone, mail, or in person, however a member of the EU or an Authorized Representative must sign the IM-110 Replacement Request form before processing.

• Lost or Stolen EBT Card: A write-up regarding the EU's statement and any additional information the ES has 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 for a lost or stolen card. If there is a police report available, this is good documentation of the time period, but it is not required.

• Food Loss Due to Household Misfortune: Details regarding the loss are needed to make a decision. It is necessary that a complete description of the loss be entered in this field.

  Example: The electricity was off for 8 hours and all food in the refrigerator and freezer was lost.

  Example: The basement was flooded and food was stored in the cupboard in the basement.

Verification of Loss

• Lost or Stolen EBT Card: Send any documentation provided by the EU regarding the loss. This can include a police report, if available, however the EU is not required to provide a police report for a lost or stolen card.
• Food Loss Due to Household Misfortune: Request verification of the loss from the EU. Examples of verification are a statement of outage from a utility company, statement of flood from disaster relief agency, or a collateral statement describing the loss.

Replacement During Appeal

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.

Submitting the Request

Continue to send completed IM-110 Replacement Request forms with verification as soon as possible to ColeFSPolicy@dss.mo.gov, or fax to 573-522-4333. If there is a delay in getting verification, to ensure meeting timeframes, send the IM-110 with a note describing verifications requested or attempts to obtain verification. File the original copy of the IM-110 in the case file.

County Determinations

During a disaster, county staff may be given access to complete these replacements. Refer to FAMIS User Guides Replacing Food Destroyed by a Household Misfortune. For replacement decisions made and entered by the county, a copy of the IM-110 must be sent to the Food Stamp Program and Policy Unit. File the original in the case record.

Before issuing a replacement benefit, check the Payment History (FM5F) screen for a replacement issuance to avoid duplicate issuances. If a replacement has been issued to the EU, a second request may be made if the EU has discovered an additional loss exceeding the original request. The total replacement cannot exceed one month's benefits. If the EU has completed more than one request contact the EU to determine the total amount of the loss. If two replacement requests are made for the same loss, deny the second request. Notify the EU of each decision by sending an IM-112 Action Taken on Your Food Stamp Case. For losses due to power outage, the power must be out at least 4 hours before a replacement can be made.

Form Availability

The WORD version of the IM-110 Replacement Request form and instructions are available on the Intranet. The combination IM-110/113 form will not be available from the warehouse. Continue to use all current copies of the IM-110 and IM-113 forms to depletion.

Food Stamp Manual Revisions

The following Food Stamp Manual sections and FAMIS User Guides have been updated to include this change:

• 1150.000.00 Replacement Issuances,
• 1150.005.00 Food Stamp Benefits Lost From an EBT Account,
• 1150.010.00 Food Purchased with Food Stamp Benefits Lost in an EU Misfortune, and
• Replacing Food Destroyed by a Household Misfortune.

NECESSARY ACTION:

• Review this memorandum with appropriate staff.

SW