Loss of Food Request

Step 1: Information About the Student

The following student information is required to submit a claim.

Student Information

Student First Name (required)

Middle

Student Last Name (required)

Date of Birth (required)

MM/DD/YYYY format

Student Sex (required)

Male

Female

Residential Address

Address (required)

City (required)

State (required)

Zip (required)

Mailing Address

Same as Residential Address

Address (required)

City (required)

State (required)

Zip (required)

Step 2: Loss/Replacement Information

Please provide information about the value of items lost and date the loss occurred. Note: You may be required to provide verification of the disaster or misfortune.

I am requesting the replacement of (required)

worth of food purchased with Summer EBT (SunBucks) Benefits that was destroyed in a disaster or misfortune (Amount cannot exceed the annual disbursement of $120.00).

Date of Food Loss (required)

MM/DD/YYYY format

Step 3: Please Explain What Happened

Please use the space below to explain how the loss occurred and remember to attach your proof.

Please explain what happened (required) Please upload supporting documentation. (required)

Be certain to redact sensitive information such as social security numbers and tax payer ids prior to uploading.

Drag and drop files here
(Allowed file types: pdf, jpg, jpeg, png, gif)

Attached Files

No files uploaded

Step 4: Please Review and Sign

I acknowledge that if this statement is not signed and returned to the Summer EBT support within 10 days of the Food Loss date reported above, benefits will not be replaced. I certify that I am aware of the penalties for intentional misrepresentation of facts, including but not limited to perjury for a false claim. I understand that the Summer EBT support has 10 days from the date this form is submitted to verify the misfortune. If verified, benefits will be distributed during the next benefit month.

I Agree to above statement

I affirm that all information provided in the fields above is for the student and it is complete and accurate and regarding Summer EBT benefits.

Your First Name (required)

Your Last Name (required)

Email (required)

Phone (required)

(000) 000-0000 format

Non-Discrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at 800-877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling 833-620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:

Mail:
Food and Nutrition Service, USDA 1320
Office of the Assistant Secretary for Civil Rights
Braddock Place, Room 334
Alexandria, VA 22314; or
Fax:
(833) 256-1665 or (202) 690-7442; or
Email:
FNSCivilRightsComplaints@usda.gov

This institution is an equal opportunity provider.

Please do not send information, such as applications or verifications, to the United States Department of Agriculture (USDA) address listed above. This address is for civil rights complaints only. Please send application materials or verifications to your local county JFS office.