NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
Division of Social Services
F.S. Case No.:
Date of Report:
Head of Household:
Reason for Report and Replacement Action:
I hereby certify under penalty of perjury and/or fraud that food purchased with my food
stamp benefits has been destroyed due to a household misfortune. The amount of
food purchased with food stamp benefits that was lost in the misfortune is
I understand that the maximum replacement amount cannot be more
than my food stamp unit's benefit amount for one month.
I hereby certify under penalty of perjury and/or fraud that my food stamp benefits were
stolen under duress. I have reported this to the appropriate law enforcement agency
and a police report has been filed.
This affidavit must be signed and returned to the Food Stamp Office within ten calendar days
of the date of report shown above, or your food stamp benefits will not be replaced.
I understand that if I am found guilty of an intentional program violation by giving false
information on purpose, I will:
Not get food stamps for 12 months the first time I am found guilty;
Not get food stamps for 24 months the second time found guilty; and
Not get food stamps for the rest of my life the third time.
Witness (if signature is by "X"
or other mark):
FOR OFFICE USE ONLY
Date Replacement Authorized:
Replacement Amount: $
DSS-1678 (Rev. 10/01)