IM-111 Electronically Stolen Replacement

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ELECTRONICALLY STOLEN BENEFIT REPLACEMENT

NAME

First Name

Last Name

Last 4 Digits of Social Security Number

DCN

PHYSICAL/MAILING ADDRESS

Street

City

State

Zip Code

Phone Number

Date of Birth

Date Discovered Loss:

I have had my EBT card with me at all times:

Yes

Skimming / Cloning: Skimming occurs when devices illegally installed on ATMs and point-of-sale (POS) terminals record card numbers and PIN. Card cloning occurs when criminals use the data captured by skimming or other means to create fake EBT cards. It is the process criminals use to copy an EBT card number without stealing the physical card itself.

Phishing/Other Similar Electronic Fraudulent Methods: Occurs when participants receive phone calls, emails or text messages from people trying to mimic state agency messaging to scam households into releasing their EBT card data.

Location I last used my EBT card:

Date I last used by EBT card:

Total Dollar Amount of Loss:

By signing this request, you are attesting that benefits were removed from your card without your permission while the card was in your possession and your PIN was secure.

FSD cannot consider your report if it has been more than 30 days since you discovered the theft.

FSD will validate claims of electronic benefit theft through EBT processor data, statements from customers, retailer data, identified skimming devices, or other similar information. FSD encourages you to provide any additional information to validate your loss such as: police report number, dates of false transactions, and retailer’s name, phone number and addresses (FSD will consider your report, even if you do not have any of this information.)

Please list fraudulent transaction information below: (additional pages may be attached, if needed)

Date

Amount

Name of Store/ATM

Theft Location City

Theft Location State

Important Information for all requests:

√ Complete, sign, and return this form to the Family Support Division (FSD) within 10 days of timely reported theft.

√ If the requested benefits were used by anyone residing in or visiting your household or by your authorized representative, no replacement will be made.

√ If benefits are stolen prior to the receipt of your Missouri EBT card, a replacement request may be considered.

√ I understand that I have the right to a Fair Hearing if I disagree with the decision to replace benefits.

USDA Nondiscrimination 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 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.

I hereby certify, under penalty of perjury and/or fraud, that benefits were electronically stolen from an EBT card without permission. I understand that if I make fraudulent statements about a loss of food or benefits, I may be ineligible to continue in the program and may be subject to prosecution under both Federal and State laws.

Electronic Signature Terms and Conditions (MUST be checked if signing or submitting electronically)

I have agreed to submit this replacement request by electronic means. By signing this replacement request electronically, I certify under penalty of perjury that all declarations made in this replacement request are true, accurate, and complete, to the best of my knowledge. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Signature of Person Requesting Benefit Replacement

Sign Date

Send your signed and completed ELECTRONICALLY STOLEN BENEFIT REPLACEMENT REQUEST by upload, fax, or mail to:

Upload to: mydssupload.mo.gov
Fax: 573-526-9400
Family Support Division

PO Box 2700

Jefferson City, MO 65102

NOTE: Please do not send any application materials to the address below. The address below is for civil rights complaints only.

You can return your application to any FSD office, by upload, or by fax.

Uploading your application: Visit mydssupload.mo.gov to upload a copy of your completed application.
Fax: 573-526-9400

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Thank You

Dear {formsubmittinguser},

Thank you for submitting an Electronically Stolen Benefit Replacement Request for SNAP benefits. Your request will be reviewed by our staff and you will receive a notice in the mail once your request has been approved or denied.

Your Replacement Request ID is {formuniqueid}.

Sincerely,

Family Support Division

FormID