Form Snap-Dhmb - Supplemental Nutrition Assistance Program (Snap) 2015
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Supplemental Nutrition Assistance Program (SNAP)
Denial of Request for SNAP Replacement Benefits for Household Misfortune
Date: ________________
This notice is to inform you that the Department has denied your request for replacement SNAP
benefits. Your request was denied because:
You did not provide a signed Statement of Loss/Request for Replacement Food Due to
a Household Disaster or Misfortune form.
Your request for replacement SNAP benefits was not made within the allowable time
frame.
You did not receive SNAP benefits for the month of_____________.
The household misfortune could not be verified.
Other
If you disagree with this decision, you have a right to a fair hearing. The reverse side of this notice
contains important information about your hearing rights. To request a fair hearing, complete the
reverse side of this notice.
______________________________
_______________________________
Department Representative Signature
Supervisor’s Signature
SNAP- DHMB (Rev. 1/2015)
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