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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Certifying Office and Case Name at the top of the form. This information is crucial for identifying your case.
- Fill in your Food Stamp Case Number, Date Reported, and Date Received. Ensure these dates are accurate to avoid any processing delays.
- Provide your Client Address, including Street, City, State, and ZIP code. This helps in verifying your identity and location.
- In the section regarding benefits issued via Administrative Terminal Application (ATA), indicate if you have not received food stamp benefits for the specified month and year.
- If applicable, fill out the Replacement Benefits section with details about any destroyed food items due to a household disaster. Include the date of the incident and the amount destroyed.
- Finally, ensure that you sign and date the affidavit at the bottom of the form. This signature certifies that all information provided is true and correct.
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