Form Cf 303 - Replacement Or Supplement Affidavit/authorization
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1State of California – Health and Human Services Agency
California Department of Social Services
REPLACEMENT OR SUPPLEMENT AFFIDAVIT/AUTHORIZATION
(CF 303)
SUPPLEMENT
Instructions: In Part A check which box(es) apply to
you, sign and return this form within 10 days of your
My household experienced one or more adverse
reported loss or no replacement can be made.
effects (loss of income, inaccessible liquid
resources, or out of pocket, unreimbursed disaster-
CURRENT HOUSEHOLD INFORMATION
related expenses) as a result of the recent disaster
that occurred in my county of residence. What
Name: ______________________________________
happened and when:
Address: ____________________________________
________________________________________
__________________________________
_______________________________________
_______________________________________
PART A - HOUSEHOLD AFFIDAVIT
_______________________________________
I,_________________________________________,
_______________________________________
declare that the household:
_______________________________________
ELECTRONIC BENEFITS TRANSFER (EBT)
I declare the above statement is true and correct to the
best of my knowledge. I also understand that if I give
EBT card was not received in the mail at the address
wrong or incomplete facts I may be disqualified from
below and the benefits have been transacted by an
the CalFresh Program, fined, imprisoned, or all three.
unauthorized person:
________________________________________
Mailing Address (Number, Street, P.O. Box)
Signature Of Responsible Household
Date
Member Or Representative
City
State
Zip
COUNTY USE ONLY
Home Address (If Different) (Number, Street)
Case Name:________________________________
Case Number:_______________________________
Worker:___________________________________
City
State
Zip
Date CF 303 Received:_________________________
PART B - REPLACEMENT/SUPPLEMENT
EBT card was reported lost/stolen to the county or
BENEFITS
to EBT hotline and the county, or the EBT hotline
APPROVED - EBT Replacement Date ____________
failed to cancel the EBT card and the benefits
APPROVED - Benefit Replacement Date __________
have been transacted by an unauthorized person.
APPROVED - Benefit Replacement Amount $ ______
Reported on _______________ at ___________
APPROVED - Disaster Supplement Date __________
Date
Time
APPROVED - Disaster Supplement Amount $_______
to______________________________________
DENIED - Reason for Denial (Explain)
________________________________________
REPLACEMENT
________________________________________
Food destroyed in household misfortune or
________________________________________
disaster. What happened and when:
________________________________________
________________________________________
________________________________________
_______________________________________
_______________________________________
Signature (Person Authorizing
Date
________________________________________
Or Denying Request)
________________________________________
Rules: These rules may apply and you may review at
_______________________________________
your welfare office MPP 16-515.
CF 303 (10/17)
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