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:

Checking your EBT history online or by downloading the ConnectEBT mobile app (available for download in the Apple App Store and Google Play Store). Or
Calling the toll-free EBT Customer Service line at 888-328-6399.

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 https://www.connectebt.com/.

* Indicates required fields

Who is filling out the form?

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.

Yes

Case Number*
Your case number has ten characters. The first nine characters are numbers, and the final character is a letter. You can find your case number on any notices HRA has sent you about your case, and also find it by logging in to ACCESSHRA. If you have multiple case numbers, or your case number has changed, enter the case number from the time period when your stolen benefits were issued.

Client Identification Number (CIN)*
Must be the CIN of the head of household/payee for the case. This is the CIN listed on your EBT card.

First Name*

Last Name*

Mailing Street Address*

Mailing Apartment/Suite

Mailing City*

Mailing State*

Mailing ZIP Code*

Email
We will send you a confirmation email with the correspondence # to this email address.

Preferred Language for Communication

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.

Date I realized my Cash benefits were stolen
This is the date when you became aware that your benefits had been stolen. It may be today or a prior day, but it needs to be within the past 30 days.

First Date Cash benefits were stolen
This is the earliest date in your transaction history where you see a fraudulent transaction. If you only see fraudulent transactions on one date, list that date here. Cash Assistance benefits stolen before January 1, 2022 are ineligible for replacement. If you are using ConnectEBT to find your transactions, please refer to "Transaction" date, NOT the "Settlement" date.

Last Date Cash benefits were stolen
This is the most recent date in your transaction history where you see a fraudulent transaction. If you only see fraudulent transactions on one date, you can leave this item blank. If you are using ConnectEBT to find your transactions, please refer to "Transaction" date, NOT the "Settlement" date.

Total Cash benefits which were stolen

Application for Replacement of SNAP Benefits

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

Date I realized my SNAP benefits were stolen
This is the date when you became aware that your benefits had been stolen. It may be today or a prior day, but it needs to be within the past 30 days.

First Date SNAP benefits were stolen
This is the earliest date in your transaction history where you see a fraudulent transaction. If you only see fraudulent transactions on one date, list that date here. SNAP benefits stolen before October 1, 2022 are ineligible for replacement. If you are using ConnectEBT to find your transactions, please refer to "Transaction" date, NOT the "Settlement" date.

Last Date SNAP benefits were stolen
This is the most recent date in your transaction history where you see a fraudulent transaction. If you only see fraudulent transactions on one date, you can leave this item blank. If you are using ConnectEBT to find your transactions, please refer to "Transaction" date, NOT the "Settlement" date.

Total SNAP benefits which were stolen

Transactions

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:

Date of Transaction 1*

Program Type 1*

SNAP Cash Assistance

Amount of Transaction 1*

Retailer Name and Location of Transaction 1*

Please provide any additional information about the theft you feel is important for us to know. If you had more than 20 fraudulent transactions to report and could not fit them on the lines above, you can list them below.

Certification

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.

Enter your name in lieu of signature*

Date Submitted*

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