Destroyed Food Benefits Form

Use the Destroyed Food Benefits Form if you lost food bought with SNAP benefits due to a disaster like a fire, tornado, or power outage.

Case Validate
Contact Info
Food Loss
Electricity Provider Info
Upload Attachment
Summary

Validate Case Number

AFS Case Number

Please enter a case number that needs to be reported. Find your case number on the front of your EBT card (letter + 6 numbers) or on any notice from OKDHS.

SSN

Please enter a SSN to match the case number.

Date of Birth

Please enter a date of birth to match the case number.

Destroyed Food Benefits Form

Case Information

Case Number

Case First Name

Case Last Name

Contact Information

Mailing Address

Mailing address, street, or PO Box

Apartment/Lot Number

City

State

ZIP Code

Email Address

Phone Number

Please enter a phone number where you can be reached

Street address or directions to your home, if different than mailing address

Destroyed Food Benefits Form

Food Loss Information

Date of Food Loss

Reason for Loss (check one):

fire

tornado

flood

loss of electricity caused by a storm

appliance malfunction caused by a storm

Date of Electricity Loss

Time of Electricity Loss

Ex: 9:00 AM, 2 PM

Date of Electricity Restoration

Time of Electricity Restoration

Ex: 9:00 AM, 2 PM

Cost of Food Loss

Please input the dollar value of the food your household lost

Attachment
Upload Document I don't have any documents to upload This is what you are submitting to DHS. You may upload up to 10 documents as long as they do not exceed 5 MB each. Select a Document Type to begin. Document Type Select Type of DocumentAuthorized Representative RequestBank/Financial StatementsBirth CertificateBurial Policy/ContractCollateral StatementCourt Orders/DocumentsDeath VerificationDoctor StatementEmployment VerificationIdentification DocumentImmunization RecordsIncome VerificationIndividual Education/Treatment PlanLife Insurance DocumentationMarriage LicenseMedical Expense VerificationMedical ID CardNursing Home Medical RecordPower of AttorneyProof of CSS PaymentsProof of OwnershipRequest for Destroyed Food ReplacementSchool Attendance VerificationShelter/Housing VerificationSocial Security CardUtility Verification Sub Document Type Select Sub Type of Document Document Description Drag files here you wish to upload, or browse for them by clicking or pressing enter . Maximum of 10 files allowed.* Max Size: 5 MB Allowed Types: DOC, DOCX, JPG, PDF, TIFF, XLS, XLSX, PNG, GIF, TXT, RTF

Attachment

Upload Document

I don't have any documents to upload

This is what you are submitting to DHS. You may upload up to 10 documents as long as they do not exceed 5 MB each. Select a Document Type to begin.

Document Type

Select Type of Document

Authorized Representative Request

Bank/Financial Statements

Birth Certificate

Burial Policy/Contract

Collateral Statement

Court Orders/Documents

Death Verification

Doctor Statement

Employment Verification

Identification Document

Immunization Records

Income Verification

Individual Education/Treatment Plan

Life Insurance Documentation

Marriage License

Medical Expense Verification

Medical ID Card

Nursing Home Medical Record

Power of Attorney

Proof of CSS Payments

Proof of Ownership

Request for Destroyed Food Replacement

School Attendance Verification

Shelter/Housing Verification

Social Security Card

Utility Verification

Sub Document Type

Select Sub Type of Document

Document Description

Drag files here you wish to upload, or browse for them by clicking or pressing enter *.
Maximum of 10 files allowed.

Max Size: 5 MB
Allowed Types: DOC, DOCX, JPG, PDF, TIFF, XLS, XLSX, PNG, GIF, TXT, RTF

Summary

Case Information

Case Number

Case First Name

Case Last Name

Contact Information

Mailing Address

Apartment/Lot Number

City

State

ZIP Code

Email Address

Phone Number

Street address or directions to your home, if different than mailing address

Food Loss Information

Date of Food Loss

Reason for Loss

Date of Electricity Loss

Time of Electricity Loss

Date of Electricity Restoration

Time of Electricity Restoration

Cost of Food Loss

Electricity Provider Information

Electric Company Name

Account Number

Account Name

If the account is not in your name, please explain