• Name: Enter the completed name of the head of the SNAP household. The person completing the form does not have to be the head of the household. S/he can be a household member or an authorized representative.
  • Residence County: Enter the name or number of the county where the household resides.
  • Social Security Number: Enter the Social Security Number of the head of the household.
  • DCN: Enter the Departmental Client Number (DCN) of the head of the household (if known).
  • Date of Birth: Enter the date of birth of the head of the household.
  • Phone number: Enter the phone number of the household.
  • Alternate phone number: Enter an alternate phone number (if available).

Social Security or MO HealthNet ID Number (DCN):


Date of Birth and Phone Numbers:

Current and Mailing Address

Current Address: Enter the complete current residence address (street, number, apt. number, etc.) of the household.

Mailing Address: Enter the address where the household receives mail (if different that the current address).

Customer Statement / Reason for Loss:
This Household Reports:

If loss is not reported within ten days of the loss, or this statement is not signed and returned within ten    days of the date the loss is reported, no replacement will be made

  • Amount of Loss: Enter the dollar amount of food or benefits lost.
  • Date of Loss: Enter the date the household experienced the loss of benefits.
  • Date Loss Reported to FSD: Enter the date the household first contacted FSD to report the loss.
  • Date Replacement Request Form Completed: Enter the date the IM-110 is completed by the household member or authorized representative.
  • Utility Provider: Enter the name of the household's electric provider if the misfortune was caused by a loss of power.
Please Describe the Circumstances Surrounding the Loss of SNAP Benefits:

Verification of loss:

  • Please provide any documentation you have to support your replacement request. Please include the name and phone number of any individual or agency contacted to document the household misfortune. If using a newspaper, enter the name and date of publication.

To the household:

For all replacement requests of SNAP benefits lost from the EBT card:

If the above benefits were used by anyone residing in or visiting your household or by your authorized representative, no replacement will be made.

If benefits are lost prior to a report of a lost or stolen Missouri EBT card, unless lost prior to receipt of the card by the household, a replacement will not be made.

If someone accesses benefits without permission from the household, a replacement will not be made unless benefits are accessed after the report of a lost or stolen card. 

Signature Section
  • After reviewing and discussing all information on the form including the statements in To The Household and Signature sections, the person reporting the loss should sign and date the form. 

I hereby certify, under penalty of perjury and/or fraud, that food purchased with SNAP benefits was lost, or that SNAP benefits were removed from an EBT card without permission. I understand that if I make fraudulent statements about a loss of food or benefits, I may be ineligible to continue in the SNAP and may be liable to prosecution under both Federal and State laws.

► Electronic Signature Terms and Conditions (box below must be checked to indicate agreement if signing electronically):

  • If signing electronically, you must review the Electronic Signature Terms and Conditions and accept them by clicking the box before filling in the name of the person completing the form on the signature line.
USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA 
Program Discrimination Complaint Form which can be obtained online
at:, from any USDA office, by calling (833) 620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for 
Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:

1. mail:

Food and Nutrition Service, USDA 

1320 Braddock Place, Room 334 

Alexandria, VA 22314; or

2. fax:

(833) 256-1665 or

(202) 690-7442; or

3. email:

This institution is an equal opportunity provider.

    Thank You

    Dear {formsubmittinguser},

    Thank you for submitting a Replacement Request for SNAP benefits. Your request will be reviewed by our staff and you will receive a notice in the mail once your request has been approved or denied. 

    Your  Replacement Request ID is {formuniqueid}


    Family Support Division