7/06

New York State Office of Temporary and Disability Assistance

Case Name:

	Case Number:

Disaster Food Stamp Benefits Assistance
Affidavit of Loss of Income/Disaster-Related Expenses

I certify under penalty of perjury that my household experienced either a loss of income or incurred disaster related expenses as a result of the flooding that occurred in my county of residence during the period June 28 through June 30, 2006.

Client Signature:

X	Date: