1678 dss fill-2026

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247 votes

The document is a Replacement/Supplement Affidavit from the North Carolina Department of Health and Human Services, Division of Social Services. It allows individuals to report lost food benefits due to household misfortunes or theft, certifying the loss under penalty of perjury. The affidavit outlines the process for requesting replacement or supplemental benefits, including eligibility criteria and consequences for providing false information. It must be signed and submitted within ten days to avoid loss of benefits.

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Click ‘Get Form’ to open the 1678 dss fill in the editor.
Begin by entering your County and FNS Case Number at the top of the form. This information is crucial for processing your request.
Fill in the Date of Report and Issuance Month/Year to ensure accurate record-keeping.
Provide your Name and Address in the designated fields, ensuring that all details are correct for correspondence.
In the Reason for Report and Replacement Action section, clearly state why you are requesting a replacement or supplement. Specify if food was destroyed or stolen, and include any relevant amounts.
Sign and date the affidavit at the bottom of the form. If you are signing with a mark, ensure a witness is present to sign as well.
Review all entered information for accuracy before submitting it back to the Food and Nutrition Services Office within ten calendar days.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (247 Votes)
2011	3.9 Satisfied (25 Votes)

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