DHS OPRMI Correspondence - Add Allegation/Complaint

NOTE ABOUT PRINTING
We recommend you take note of the Stolen Benefits record identifier. Your submission must be completed by clicking either the Save button on the top right corner of the screen or at the end of the form before attempting to print this form. Use your web browser's built-in functionality to print by selecting Print from the File menu. Some browsers may allow you to right-click anywhere on the page and select a Print shortcut.
You will not be able to log into QuickBase to edit or email it. If you wish to change or add to your email complaint, please email oprmi@dc.gov with the Stolen Benefits in the subject line and include any additional information and attachments in the email.

You will only be able to view and print your form from the link.

STOLEN BENEFITS
You will be required to submit a completed DHS-1697 claim form and to get a replacement card before a claim is considered complete. After you submit your completed DHS-1697 claim form, OPRMI will need to verify that a loss occurred and that all required steps were completed. If your loss is verified, DHS will issue replacement benefits within Forty-Five (45) business days after all required steps are completed.
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DHS may deny your request for replacement benefits if you do not submit a completed DHS-1697 claim form reporting your loss within thirty (30) days of the date you became aware of the loss or if available evidence is insufficient to validate your request for replacement benefits. DHS can only replace SNAP up to the lesser of either the amount of benefits stolen or the amount equal to two (2) months of your monthly allotment immediately prior to the date when the benefits were stolen. SNAP benefits can only be replaced two times per program within a federal fiscal year (October 1 to September 30).

Important Notes: To Submit Stolen Benefits Claim for Mobile Users

Stolen Benefits Type *

Cash
SNAP

Customer Requirements

First Name *

Middle Name

Last Name *

Date of Birth *

Email Address

Phone Number *

Address *

Apt Number

City *

State *

Zip Code *

Case Number #

Card Number (Last 8 Digits of EBT Card #) *

Please enter last 4 digits of EBT Card Number

Claim Details

How was your card compromised? *

Skimming
Cloning
Other Fraudulent methods

On what date did you discover your benefits were stolen? *

Have you requested a replacement EBT card *

Yes
No

Date EBT card was requested?

Was your EBT card lost or stolen? *

Yes
No

Did you have your EBT card with you when your benefits were stolen? *

Yes
No

Transactions

PLEASE LIST ALL TRANSACTIONS that you are claiming were stolen due to card skimming, cloning, or similar fraudulent methods below. If you need to report additional transactions, please print and complete an additional copy of this page. Items marked with an asterisk (*) are required.

List each transaction on a separate line. Do not combine transactions that occurred at the same store/bank. If you need to confirm transaction details, you can call DHS s EBT card provider, FIS, at (888) 304-9167 or view your transaction history online at ebtedge.com or on your phone with the ebtEDGE mobile app.

List each transaction on a separate line, please double click on each box under the field name to enter the details

New Transactions More

0 Transactions records

	Date of Transaction *	Time of Transaction	Store/Bank Name	Store/Bank Address or City/State (if Known)	Transaction Amount

Total Transaction Amount

Certification And Signature

PENALTY ACKNOWLEDGEMENT

I understand that by signing this form, I am representing that the information I provided for this claim is true and accurate to the best of my knowledge, information, and belief.

I understand that misrepresentations of theft and/or false statements to DHS are a violation of DC and federal laws, and if I break these laws then I may be fined, go to prison, and/or be disqualified from program participation and not be able to receive benefits. I acknowledge that if I have knowingly given incorrect information about the facts stated above, I may be charged with an Intentional Program Violation (IPV) and/or may be subject to administrative, civil, or criminal penalties including, but not limited to, perjury for a false claim.

CERTIFICATION AND SIGNATURE

I authorize DHS to contact any person, partnership, corporation, association, or governmental agency that may have information relevant to this claim. I also authorize any person, partnership, corporation, association, or governmental agency which has information relevant to this claim to release that information to DHS.

I understand that if I do not submit a claim to DHS within thirty (30) days of the date I became aware of the loss of my benefits, DHS will not replace my benefits. I also understand this request for replacement of stolen benefits is not complete until I complete a DHS-1697 claim form and request a replacement EBT card.

I understand that the submission of this claim does not guarantee that my benefits will be replaced. I understand I have a right to a Fair Hearing if my request for replacement benefits is denied or delayed, and that replacement benefits will not be issued while a Fair Hearing decision is pending.

I swear or affirm that I have read or had read to me this entire application, including the penalty acknowledgement. I also swear or affirm, under penalty of perjury, that all the information I have given is true, correct, and complete to the best of my knowledge, information, and belief.

Type Your Name *

Person Signing *

Self
Authorized Representative Relationship to Person Submitting Claim
DHS Representative

Date of Submission

Sunday, JUL-13-25

Admin

# of Reported Transactions

# of Transactions records

RIS

Field label
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Justification
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