FOOD ASSISTANCE REPLACEMENT AUTHORIZATION

STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES FOOD ASSISTANCE PROGRAM

FOOD ASSISTANCE REPLACEMENT AUTHORIZATION

Under penalty of perjury and/or fraud, I certify that my household lost food due to spoilage because of damage or power outage caused by a fire or natural disaster. I purchased this food with food assistance benefits.

First Name

Middle Initial

Last Name

Address

County

Case Number

Value of food lost or destroyed:$

Date of Loss, spoilage, or damage

Phone number

Draw Signature

with mouse or touch

The form is due no later than 10 days after the date of the loss.