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Claim Form for Replacing Electronically Stolen Benefits

Claim form for Replacing Electronically Stolen Benefits

You can use this form to request the replacement of SNAP and/or CA benefits which were stolen electronically through skimming, phishing, or other similar fraudulent methods. Please see detailed instructions for completing the form.

To submit a claim, you must provide specific information about the fraudulent transactions. You can find this information by:

Please note, if you have been skimmed and have not reported your EBT card lost or stolen, your account is likely still at risk. No replacement benefits may be issued until you have reported your compromised EBT card lost or stolen. To report your card stolen, request a new card, and change your PIN, please call EBT Customer Service at 888-328-6399, or go to

* Indicates required fields

Household Information

Please confirm: I reported my card as lost or stolen after realizing my benefits had been stolen*
If you already reported your card as lost or stolen after the theft, you do not have to report it lost or stolen again.

Benefit Theft Information

We will first ask for summary information about the total amount of benefits which were stolen. We will ask you to report specific fraudulent transactions in the next section.

I am the head of household or an adult household member for the above-named case and wish to report fraudulent transaction(s) on my EBT card.

Application for Replacement of Cash Assistance Benefits

If you have not had any Cash Assistance benefits stolen, please skip this section and move onto the next section.

Application for Replacement of SNAP Benefits

If you have not had any SNAP benefits stolen, please skip this section.


List each fraudulent SNAP or Cash Assistance transaction on a separate line, even for purchases occurring on the same date or at the same retailer. Refer to instructions above. These transactions should total up to the total amount of theft you reported in the section above for SNAP and Cash Assistance. Please carefully indicate the dates, amounts, retailer name and location, and whether the fraudulent transactions were from your SNAP or Cash Assistance case. If you are using ConnectEBT to find your transactions, please refer to "Transaction" date, NOT the "Settlement" date.

Please list the transactions that were not made by you:

Program Type 1*


Do not sign until you have read and understand the statement below.

I understand and agree to the following:

  • I must complete, submit, and sign this form to request the replacement of stolen benefits.
  • The information provided in this request is true and accurate.
  • The submission of this request does not guarantee that my benefits will be replaced.
  • If I have knowingly given incorrect information about the facts stated above, I may be charged with an intentional program violation (IPV) and may be subject to civil and criminal penalties including, but not limited to, perjury for a false claim.
  • I have a right to a fair hearing to contest the denial or delay of replacement issuance for my household. Replacement would not be issued pending the fair hearing decision.

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