The following student information is required to submit a claim.
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.
Please use the space below to explain how the loss occurred and remember to attach your proof.
Be certain to redact sensitive information such as social security numbers and tax payer ids prior to uploading.
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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.
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:
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.