Dfa Form 474 - Attestation And Verification Of Food Stamp (Fs) Household Disaster

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NH Department of Health and Human Services (DHHS)
DFA Form 474
Division of Family Assistance (DFA)
08/15 rev 4/16
ATTESTATION AND VERIFICATION OF FOOD STAMP (FS) HOUSEHOLD DISASTER
To get replacement FS benefits for food destroyed in a disaster you must tell us about the disaster within 10 days
of it happening
After telling us about the disaster
use this form to attest to and prove the disaster (fire
flood
.
,
,
,
power outage
etc
) in which you lost food bought with FS benefits
You must complete both Parts of this form
You
,
.
.
.
must then return it to us within 10 days of telling us about the disaster
The dollar amount that is replaced will
.
not be more than your monthly benefit allotment
.
You must tell us the date of the disaster
and the value of food lost
You must also give us proof of the disaster
,
.
.
Failure to do so could result in a denial or delay of you getting your replacement FS benefits
.
P
A
R
FS B
R
ART
EPLACEMENT
ENEFITS
EQUEST
:
Name of FS Household Member
Case Number
Street Address
Phone #
City/Town
State
Zip
that I lost food bought with my household’s
I attest under penalty of unsworn falsification
pursuant to RSA 641
3
,
:
,
FS benefits
due to ________________ (example
fire
flood
power outage
etc
)
and that I have read and
,
:
,
,
,
.
,
understand the penalties for giving false information explained on the back of this form
.
$
Date of Disaster
Value of food lost that was bought with
your FS benefits
Signature of FS Household Member
Date
P
B
P
D
(
)
ART
ROOF OF
ISASTER
FIRE
FLOOD
POWER OUTAGE
ETC
:
,
,
,
.
You must give us proof that your household had a disaster
Do you have a letter from an agency
such as an
.
,
insurance company
Fire Department
power company
or Red Cross? If so
you do not have to complete this Part
,
,
,
,
.
That letter from the agency is proof of your disaster
If you include that letter when you return this form
you only
.
,
need to complete Part A above
If you do not have a letter from an agency about your disaster
you must either
.
,
:
Have someone other than yourself fill out the box below
This person could be your landlord
neighbor
or any
.
,
,
other person who is not a member of your FS household and knows about the disaster
.
that the above named person’s statement is
I attest under penalty of unsworn falsification
pursuant to RSA 641
3
,
:
,
true and accurate to the best of my knowledge
.
Printed name
________________________________________ Phone number
_____________________
:
:
Relationship to household
__________________________________________________________________
:
Signature
_____________________________________________________________ Date
____________
:
:
OR
If you cannot reach anyone who can fill out the above box
we can try to reach someone for you
Tell us this
,
.
person’s name
contact information
and relationship to you
This person may work for an agency
such as an
,
,
.
,
insurance company
Fire Department
power company
or the Red Cross
This person could also be your
,
,
,
.
landlord
neighbor
or any other person who is not a member of your FS household and has knowledge of the
,
,
disaster
.
Name
___________________________________________________ Phone #
______________________
:
:
Relationship to you
_______________________________________________________________________
:
Return this form to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301
DFA SR 15-13
CentralizedScanUnit@dhhs.state.nh.us
(A)

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