INDIVIDUAL REPLACEMENT REQUEST

STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES FOOD ASSISTANCE PROGRAM

INDIVIDUAL REPLACEMENT REQUEST

Under penalty of perjury and/or fraud, I certify that my household lost food due to spoilage because of damage or power outage caused by a fire or natural disaster. I purchased this food with food assistance benefits.

* First Name

Middle Initial

* Last Name

* Address Line1

Address Line2

* City

* Zip

* State

* County

* Case Number

SSN

* Date of Birth

* Value of food lost or destroyed: $

* Date of Loss, spoilage, or damage

* Phone number

I agree to submit this application by electronic means. By signing this form electronically, I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES FOOD ASSISTANCE PROGRAM

INDIVIDUAL REPLACEMENT REQUEST

Draw Signature

e-signature