Form Cf 303 Replacement Affidavit/authorization
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REPLACEMENT AFFIDAVIT/AUTHORIZATION
COUNTY USE ONLY
(CF 303)
Case Name:
Case Number:
Instructions: In Part A check which box(es) apply to you, sign and
Worker:
return this form within 10 days of your repor ted loss or no
Date CF 303 Received:
replacement can be made.
PART A - HOUSEHOLD AFFIDAVIT
I,____________________________________________________,
PART B - REPLACEMENT BENEFITS
declare that the household:
■ ■
APPROVED - EBT Replacement Date _____________________
■ ■
Electronic Benefits Transfer (EBT) card was not received in the
■ ■
mail at the address below and the benefits have been transacted
EBT: Authorized Replacement Amount $___________________
by an unauthorized person:
■ ■
DENIED - Reason for Denial (Explain)
____________________________________________________
Mailing Address (Number, Street, P.O. Box)
____________________________________________________
_________________________________________________
City
State
Zip
____________________________________________________
_________________________________________________
____________________________________________________
Home Address (If Different) (Number, Street)
_________________________________________________
SIGNATURE (PERSON AUTHORIZING OR DENYING REQUEST)
DATE
City
State
Zip
PART C - ACKNOWLEDGEMENT OF RECEIPT (OVER THE
_________________________________________________
COUNTER)
■ ■
RECEIVED BY:
DATE
EBT card was reported lost/stolen to the county or to EBT
hotline and the county, or the EBT hotline failed to cancel the
EBT card and the benefits have been transacted by an
unauthorized person.
Reported on ________________________ at ______________
DATE
TIME
to_________________________________________________
■ ■
Food destroyed in household misfortune or disaster. What
happened and when:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
I declare the above statement is true and correct to the best of my
knowledge. I also understand that if I give wrong or incomplete facts
I may be disqualified from the CalFresh Program, fined, imprisoned,
or all three.
SIGNATURE OF RESPONSIBLE HOUSEHOLD MEMBER OR
DATE
REPRESENTATIVE (WHO GOT REPLACEMENT)
☛
Rules: These rules may apply and you may review at your welfare
office MPP 16-515.
CF 303 (2/14) REQUIRED FORM - SUBSTITUTES PERMITTED
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