Form H1855 "Affidavit for Nonreceipt or Destroyed Food Stamp Benefits" - Texas

What Is Form H1855?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form H1855 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form H1855 "Affidavit for Nonreceipt or Destroyed Food Stamp Benefits" - Texas

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Form H1855
April 2003-E
Affidavit for Nonreceipt or Destroyed Food Stamp Benefits
Food Stamp Case No.
Certifying Office
Case Name
Date Reported
Date Received
Address Field
City
State
ZIP Code
Benefits Issued via Administrative Terminal Application (ATA)
Month/Year
My household has not been issued and has not received food stamp benefits for the month of ...................
Replacement Benefits
Old Address (if applicable)
Benefit Month/Year
Allotment Amount
Original Issuance No.
Original Issue Date
Some of my household's food bought with food stamp benefits was destroyed in a household disaster on
The amount destroyed was ................................................................................................................
If this affidavit is not signed and received by the local office within 10 days of the date of the report, no
replacement will be made.
I certify that the statement checked above is true and correct. I understand that anyone who obtains or uses food
stamp benefits for which he is not eligible can be charged with a criminal offense. If convicted, he may be fined,
imprisoned, or both.
Signature — Head of Household or Responsible Family Member
Date
Form H1855
April 2003-E
Affidavit for Nonreceipt or Destroyed Food Stamp Benefits
Food Stamp Case No.
Certifying Office
Case Name
Date Reported
Date Received
Address Field
City
State
ZIP Code
Benefits Issued via Administrative Terminal Application (ATA)
Month/Year
My household has not been issued and has not received food stamp benefits for the month of ...................
Replacement Benefits
Old Address (if applicable)
Benefit Month/Year
Allotment Amount
Original Issuance No.
Original Issue Date
Some of my household's food bought with food stamp benefits was destroyed in a household disaster on
The amount destroyed was ................................................................................................................
If this affidavit is not signed and received by the local office within 10 days of the date of the report, no
replacement will be made.
I certify that the statement checked above is true and correct. I understand that anyone who obtains or uses food
stamp benefits for which he is not eligible can be charged with a criminal offense. If convicted, he may be fined,
imprisoned, or both.
Signature — Head of Household or Responsible Family Member
Date