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Form Nfl-9-9- B - Notice Of Denial Of Snap Replacement Benefits Due To Household Disaster Or Misfortune 2014

Massachusetts Department of Transitional Assistance

Notice of Denial of SNAP Replacement Benefits Due to Household Disaster or Misfortune

Date

This notice is to inform you that your request for SNAP replacement benefits due to household disaster or misfortune

is denied. It is denied because:

You did not receive SNAP benefits in the month of

You did not provide verification of the household disaster or misfortune (such as loss of power, equipment

failure or flood) by a third party

You did not sign the Statement of Loss/Request for Replacement Food (form 9-B)

You did not provide the amount of the loss of food

You did not report the loss of food within 10 days of the loss (or within the allowable time frame)

Other reason(s) and policy citation(s):

Citation: 106 CMR:364.900(c)

If you would like to review the information or documentation supporting the Department’s decision, please contact

DTA at 1-877-382-2363.

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 hearing, complete the back side of this notice. The regulation(s) used in

reaching these decisions are 364.900(c).

Department Representative’s Signature

Supervisor’s Signature

NFL-9-9-B

(Rev. 10/2014)

Original and Copy to Client – Copy to Case Record

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Form Nfl-9-9- B - Notice Of Denial Of Snap Replacement Benefits Due To Household Disaster Or Misfortune 2014