M E M O R A N D U M

IM-54  05/05/99  IM-110 FORM AND INSTRUCTIONS


SUBJECT:
STATEMENT OF LOSS/REPLACEMENT REQUEST
FORMS MANUAL REVISION #17:  IM-110 FORM, STATEMENT OF LOSS/REPLACEMENT REQUEST FORM AND INSTRUCTIONS PAGES 1 AND 2
 
DISCUSSION:
The IM-110 form, Statement of Loss/Replacement Request, is revised to reflect Electronic Benefit Transfer language.  The reference to ATP cards and coupons is removed.

The form is used to provide a statement of loss when food purchased with food stamp benefits is destroyed.  The loss must be due to household misfortune, such as fire or flood.  Policy for completing the IM-110 form is not changed.  The participant must sign and return the form to the county office within 10 days of the date the loss is reported.  No replacement will be made for participants that do not return the IM-110 form timely.

The revised form is being printed and, upon completion, an initial supply will be sent to county offices.  Upon receipt of the revised IM-110, destroy all former revisions.
 
NECESSARY ACTION:
  • Discuss this memorandum with all appropriate staff.

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  • Destroy all former revisions of the IM-110 upon receipt of an initial supply of the revised form.

    •  
  • File the revised IM-110 form and instructions in the IM Forms Manual.
REM
Distribution #3
Form not available on-line.  Refer to IM Forms Manual.
[ 1999 Memorandums ]