FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner

James K. Whelan, Deputy Commissioner Stephen Fisher, Assistant Deputy Commissioner Policy, Procedures, and Training Office of Procedures

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Call 718-557-1313 then press 3 at the prompt followed by 1 or send an e-mail to FIA Call Center Fax, or fax to (917) 639-0298

Distribution: X

POLICY DIRECTIVE #12-16-ELI

(This Policy Directive Replaces PD #02-41-ELI and PB #04-116-OPE)

FOOD STAMP CHANGE REPORTING RULES AND PERIODIC REPORTING

Date: June 13, 2012

Subtopic(s): Food Stamps

AUDIENCE The instructions in this policy directive are for Non Cash Assistance Food Stamp (NCA FS) Center staff and Income Clearance Program (ICP) staff. They are informational for all other staff.

POLICY Households in receipt of Food Stamp (FS) benefits, are subject to

change reporting requirements as follows: New York State Nutrition Improvement Project (NYSNIP) See PB #04-105-ELI for NYSNIP information.

Households in receipt of NYSNIP benefits have 48 month certification periods and are not required to report any changes during the certification period. However, these households are sent a NYSNIP Food Stamp Benefits Interim Report (NYC) (LDSS-4836 NYC) at the end of the 23rd month of their certification period which must be completed and returned by the tenth day of the 24th month of their certification period, regardless of whether or not the household has any changes to report. If the NYSNIP household incurs a change that will increase their FS benefit, the change must be acted on if verification of the change is provided.

Transitional Food Stamp Benefits See PD #10-03-ELI for Transitional Food Stamp Benefit information.

Households in receipt of Transitional Food Stamp Benefits (TFSB) are not required to report any changes during their five month transition period. TFSB households may report changes during the transition period that will result in an increase in FS benefits, but the household is required to file a new recertification application and be recertified before any increase in FS benefits can be authorized during the five month transition period.

PD #12-16-ELI

Ten Day Change Reporting Households The following non-NYSNIP and non-TFSB households are subject to the ten day FS change reporting rules that require households to report certain changes within ten days after the end of the month in which the change occurred.

See PB #08-01-ELI for information on change reporting households.

• Households in which all adults are elderly or disabled without

earned income • Migrant or seasonal farm worker households • Homeless (undomiciled – shelter code 23) households • Households with no income (earned or unearned) • Households certified for less than four months • Group home residents in receipt of Supplemental Security

Income (SSI) or Social Security Disability (SSD) Households subject to ten day FS change reporting rules are required to report the following changes within ten days after the end of the calendar month in which the change occurred:

• Changes in any source of income for anyone in the household

• Changes in the household’s total earned income when it increases or decreases by more than $100 per month

• Changes in the household’s total unearned income from a private source when it increases or decreases by more than $100 per month

• Changes in the household’s total unearned income from a public source when it increases or decreases by more than $50 per month

• Changes in household composition • Changes in residence • Changes in rent or mortgage for households that move to a

new residence • Changes in the amount of court-ordered child support that the

household is required to pay for a child residing outside of the FS household when it increases or decreases by more than $50 per month

• For households subject to the resource limit, any change that will cause the household to exceed the resource limit

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Six-month Reporting Households

All other non-NYSNIP, non-TFSB, and non-ten day FS change reporting FS households are six-month reporters and are subject to six-month reporting rules. These households will be mailed a Periodic Report (LDSS-4310) in the fifth month of their twelve month certification period which they must complete, sign, and return by the tenth day of the sixth month of their certification period.

See PB #08-13-OPE for information on six-month reporting rules for FS households.

Except at recertification and on the Periodic Report, the only two changes that six-month reporting households must report are if the household’s gross income exceeds 130% of the poverty level and if the household contains an Able Bodied Adult Without Dependents (ABAWD) and the ABAWDs work hours go below 80 hours per month. Either of these changes must be reported within ten days after the end of the calendar month in which the change occurred.

FS households that are subject to six-month reporting rules are sent the Important Information About What Changes You Must Report For Food Stamps (LDSS-4791) each year, which lists the monthly, weekly, and bi-weekly 130% poverty levels for their household size.

This policy directive provides instructions regarding the processing of Periodic Reports for NCA FS households.

Effective May 2008, the certification period for NCA FS households subject to six-month reporting rules was extended from six months to twelve months. However, in order to comply with reporting rules that were previously met by semiannual recertifications, these households are required to complete, sign, and return a State issued Periodic Report in the sixth month of their twelve month certification period.

BACKGROUND

All NCA FS households subject to six-month reporting rules that have a twelve-month certification period will be mailed the Periodic Report on or about the Monday following the third Saturday of the fifth month of their certification period. The FS household must complete, sign, and return the Periodic Report by the tenth day of the sixth month of their certification period (to be considered timely) even if the household has no changes to report.

The Periodic Report (LDSS-4310) must be signed, completed, and returned even if the household has no changes to report.

The processing of a failure to complete, sign, or return the Periodic Report will result in a timely closing notice being sent to the household. The closing notice will include the Follow-Up to the Periodic Report (LDSS-4310A) and a postage paid return envelope.

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If the household completes, signs, and returns a Periodic Report or a Follow-Up to the Periodic Report prior to the case actually closing, the closing action must be settled in conference (SIC).

However, although the closing process may begin on the eleventh day of the sixth month of the certification period for FS households who fail to return the Periodic Report in a timely manner, the household has until the last day of the sixth month of the certification period to comply to avoid a loss of FS benefits and a need to reapply for continued FS benefits.

For example, a FS household is mailed a Periodic Report on April 23rd and fails to return the Periodic Report by May 10th as instructed. On May 11th, a closing action is initiated that generates a Notice of Intent (NOI) to close the FS case. The FS household fails to resolve the issue during the NOI period and the FS case closes on May 25th. On May 30th, the FS household submits a completed and signed Periodic Report. The closed FS case must be re-opened and any lost FS benefits must be issued. However, if the FS household fails to submit a completed and signed Periodic Report by May 31st, the household must reapply to receive continued FS benefits.

Once a case has been placed on a six-month reporting cycle, the household remains subject to the six-month reporting rules, regardless of circumstances, until the next recertification.

What happens if the household moves into an exempt category during a six-month cycle?

For example, a household with a twelve month certification period that is subject to the six-month reporting rules loses all of its income during the certification period. The budget can be adjusted whenever the household verifies the loss of income, but the household is still subject to the six-month reporting rules (including the return of a signed and completed Periodic Report) until the end of the certification period. At that point, if the household still has no income, the case will become subject to ten day change reporting rules.

ICP Web System To further enhance this process, Management Information Systems (MIS) has developed the ICPWeb system that serves as a tracking mechanism used by ICP staff to enter information concerning Periodic Reports received and those returned as undeliverable. The ICPWeb also performs TALX and Resource File Integration (RFI) matches on all cases sent a Periodic Report. Instructions on how to access and enter information into the ICPWeb system are contained in the ICPWeb Instructions (Attachment A).

See PD #11-11-EMP for the TALX procedure. See PD #09-43-SYS and PB #11-39-SYS for RFI processing information.

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PD #12-16-ELI

The ICPWeb passes files directly to the Welfare Management System (WMS) to initiate case closings for households that fail to comply with the periodic reporting process and to SIC pending periodic reporting closings for households that return a signed and completed Periodic Report before the case actually closes.

For households that fail to return the Periodic Report in a timely manner, the ICPWeb sends a file to WMS to initiate a case closing using closing code E50 (Failed to Return 6 Month Periodic Report).

For Periodic Reports returned by households, ICP staff must scan and index the Periodic Report and any enclosed documentation into the ICPWeb. Periodic Reports returned by the Post Office as undeliverable and the envelope stamped as “undeliverable” must also be scanned and indexed into the ICPWeb. After scanning and indexing, ICP staff reviews the Periodic Report for completeness and signature so they can make the appropriate selections in the ICPWeb. ICP staff will also data enter the household’s written responses to the questions on the Periodic Report into the ICPWeb.

REQUIRED ACTION

The ICPWeb contains a function labeled BULK RECEIVE, which allows ICP staff to data enter the receipt of Periodic Reports into the ICPWeb by solely entering the case number and whether or not the Periodic Report is signed and completed. The bulking process allows for a faster decontrol of the Periodic Reports that may be necessary to ensure that households that return a Periodic Report in a timely manner are not included in the file sent by the ICPWeb to WMS to initiate a case closing for failure to return the Periodic Report.

BULKING process.

For cases that have undergone the bulking process, the temporarily delayed scanning, indexing, and data entry of the household’s responses on the Periodic Report, must be completed by ICP staff in a timely fashion to allow sufficient time to process any required budgetary changes by the seventh month of the household’s certification period.

The following sections in this procedure list the process for handling Periodic Reports that are:

• Returned unsigned • Returned incomplete • Returned signed and completed • Returned by the Post Office as undeliverable • Hand delivered to the Food Stamp Center

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Periodic Reports Returned Unsigned

ICP :

ICP staff must select “Incomplete” in response to the question “Is the Recertification/Eligibility Questionnaire?” After selecting “Incomplete” the statement “Reasons for Incomplete” will appear and ICP staff must select “Incomplete Signature”.

ICP Web : Based on this response, the ICPWeb will send a file to WMS to close the case using closing code E52 (Failure to Complete 6 month Periodic Report – Signature).

Periodic Reports Returned Incomplete Periodic Reports are incomplete if the household failed to answer the questions on the report. Additionally, if the household answered “Yes” to the question “Have there been any other changes since your last Report, or do you expect any changes?” but failed to check any of the checkbox options below it, the report is considered incomplete.

ICP : ICP staff must select “Incomplete” in response to the question “Is the Recertification/Eligibility Questionnaire?” The statement “Reasons for Incomplete” will appear and ICP staff must select “Incomplete Questionnaire”.

Note: If the Periodic Report is returned both unsigned and incomplete, select the option “Incomplete Signature”.

ICPWeb : Based on this response, the ICPWeb will send a file to WMS to close the case using closing code E51 (Failure to Complete 6 month Periodic Report–Questions).

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Periodic Reports Returned Signed and Completed ICP : In the ICPWeb, ICP staff must select “Complete” in response to the question “Is the Recertification/ Eligibility Questionnaire?” After selecting “Complete”, the question “Is the Periodic report with No Change & No Document?” will appear. ICP staff must select “Yes” if there are no changes and no enclosed documentation or “No” if there are any changes and/or any enclosed documentation.

ICPWeb : The ICPWeb will transmit the information entered by ICP staff into the Food Stamp Paperless Office System (FS POS). If there is a closing clocking down for failure to comply with the periodic reporting process, the ICPWeb will pass a file to WMS to SIC the closing.

NCA FS Center 25 : Information concerning the Periodic Report that is loaded by the ICPWeb into FS POS will appear in the new “NCA Periodic Mailer” queue in the FS Change Case Data window and will be handled by workers at the Special Projects Food Stamp Change Center (F25).

NCA Periodic Mailer Queue in FS POS

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PD #12-16-ELI

The Changes to the Active FS Case window in the FS Change Case Data activity was updated to accommodate this process.

Supervisors at F25 will assign the cases that are loaded into the NCA Periodic Mailer queue to the Workers at F25 who will:

• review the data loaded into FS POS for each Periodic Report

• review a copy of the Periodic Report and any documentation submitted by the household in the HRAViewer

• review any TALX and/or RFI match information which is located in the FS Change Case Data window

• determine if any changes need to be made in WMS

Periodic Reports With No Changes

If the F25 Worker determines that there are no changes on the case, he/she will input a comment in FS POS that the household complied with the periodic reporting process and there were no changes on the case. A new WMS budget is

not required for no change cases.

Processing Periodic Reporting Changes

Information submitted on or with a signed and completed Periodic Report that will result in a decrease or termination of FS benefits must be processed (even if the change is not verified) unless the change is due to a decrease in a simplified deduction. Simplified deductions are non-move shelter expenses, medical or dependent care expenses.

Decrease in FS benefits

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Households whose FS benefits will be reduced or terminated as a result of information submitted on or with a signed and completed Periodic Report are only entitled to receive adequate notice. To ensure that a timely notice is not provided in these instances, the Worker must enter code A (manual notice – adequate action) in the M3E Indicator field (element 053) on the Turn-Around-Document (LDSS-3517), when taking an action that will reduce or terminate the household’s FS benefits.

Households whose FS benefits would increase as a result of information submitted on the Periodic Report (e.g. a decrease in income, an increase in expenses, or an increase in household size),

Increase in FS benefits

cannot receive an increase in FS benefits until verification of the change has been provided. If the household did not include documentation to verify a change reported on the Periodic Report that would result in an increase in FS benefits, the Worker must mail the household the Notice of Documentation Required – Change in Household Circumstances

Reported change that will increase FS benefits not verified.

(W-132S) which informs the household that they must verify any changes that will entitle them to an increase in FS benefits. Along with Form W-132S, the Worker must mail the household the Eligibility Factors and Suggested Documentation Guide (W-119D) and a postage paid return envelope addressed to the household’s Home Center.

Households that return a signed and completed Periodic Report in a timely manner are considered to have complied with the periodic reporting process and are

Do not close the FS case for failure to provide documentation. not to be closed for failure to submit

documentation with the Periodic Report. As a household’s FS case cannot be closed for failure to submit documentation along with the Periodic Report, the FS Worker at F25 is

to complete the case without applying the unverified changes if those changes would have resulted in an increase in FS benefits. The FS Worker must enter a comment in FS POS that the case was processed without applying the changes because the household failed to include verification of the changes that would have increased the household’s FS benefits. If the FS household submits verification of the changes at a later date, the changes will be acted upon by the Home Center.

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Once the FS Worker at F25 has completed all the required actions for the periodic reporting process, the case will be forwarded to the supervisor’s queue. The Supervisor at F25 will:

• review the case (using the Approve FS Change Case Data

activity in FS POS Centers) to ensure that all required actions were taken; and

• complete the approval process in a timely manner to ensure that any change in FS benefits or closing action is effective for the seventh month of the household’s certification period.

Periodic Reports Returned as Undeliverable ICP : ICP staff must select “Undelivered” in response to the question “Is the Recertification/ Eligibility Questionnaire?” After selecting “Undelivered”, two separate text boxes will appear, the first containing the case address that the Periodic Report was mailed to and the second containing the current address in WMS. In response to the question “Is case Address and WMS Address different?” select “Yes” if they are different and “No” if they are the same.

ICPWeb : If ICP staff selected “No” (address is the same) the case will be included in the file ICP passes to WMS of cases that fail to respond to the Periodic Report in a timely manner. If ICP staff selected “Yes” (address is different) the ICPWeb will transmit the information to FS POS and will

not include the case in the file ICP passes to WMS of cases that fail to respond to the Periodic Report in a timely manner. NCA FS Center 25 : If ICP staff selected “Yes” (address is different), the FS Worker at F25 will make sure that the address in WMS is correct by matching it against the documentation in the HRA Viewer. If the address in WMS is correct, the Worker will mail the household a new LDSS-4310 and a postage paid return envelope. The LDSS-4310 must be annotated with a due date of at least ten calendar days from the mailing date. A comment should be made in FS POS that a new Periodic Report was mailed because the previously mailed report was sent to a prior address. If an E50 closing is clocking down, process an SIC and if the case is already closed with code E50, re-open the case.

Address on the Periodic Mailer does not match the address listed in the ICPWeb. See PB #12-15-SYS for new Food Stamp Settle in Conference Activity in FS POS.

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If the household returns a signed and completed Periodic Report by the new date, the FS Worker at F25 will:

• review the Periodic Report and any documentation submitted

by the household; • review any TALX and/or RFI match information • determine if any changes need to be made

If any changes need to be made in WMS, process the required actions in FS POS. If the household’s FS benefits will be terminated or reduced as a result of information submitted on or with the Periodic Report, only provide the household adequate notice.

If the household fails to return the LDSS-4310 by the new due date, the FS Worker at F25 will close the case using closing code E50.

Periodic Reports Hand Delivered to the Food Stamp Center

If an individual brings a Periodic Report to a Food Stamp Center, the Front Door Receptionist (FDR) will give the individual a ticket to FS Reception/NCA General. In Non-Model Offices the individual will go directly to the FS Receptionist.

Participant brings the Food Stamp Periodic Report to his/her Food Stamp Center

The FS Receptionist will make sure that the individual has properly signed and completed the Periodic Report and will check WMS to determine the current status of the case.

If the case is active, the FS Receptionist will give the signed and completed Periodic Report to the designated Worker who will scan and index the Periodic Report and any enclosed documentation.

Case is active

The ICPWeb will retrieve the scanned and indexed Periodic Report and any supporting documentation that was also scanned and indexed at the same time and will place the information into a queue for ICP staff to process. The ICPWeb has been updated to allow ICP staff to enter information contained on these Periodic Reports into the ICPWeb. The ICPWeb will transmit the information entered by ICP staff into FS POS for F25 processing. If a closing is clocking down for failure to comply with the periodic reporting process, the ICPWeb will pass a file to WMS to SIC the closing.

If the case is closed for failure to comply with the periodic reporting process, but the household has submitted the signed and completed Periodic Report to the Home Center

Household submits the Periodic Report before the end of the sixth month of the certification period.

before the end of the sixth month of the household’s certification period, the Periodic Report and any attached documentation must be given to the Home Center’s Mail Processing Unit to process the re-opening of the case.

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If the case is closed for failure to comply with the periodic reporting process, and the household submits a Periodic Report to the Home Center

Household submits the Periodic Report after the end of the sixth month of the certification period. after the end of the sixth month of the certification period, the

FS Receptionist must inform the individual that he/she must reapply to receive continued FS benefits.

PROGRAM IMPLICATIONS POS Implications Workers are to make all required changes and closing actions

through FS POS in the FS Change Case Data activity. Medicaid Implications

There are no Medicaid implications. For Limited English Proficient (LEP) and hearing-impaired participants, make sure to obtain appropriate interpreter services in accordance with

LIMITED ENGLISH PROFICIENT (LEP) AND HEARING IMPAIRED IMPLICATIONS

PD #11-33-OPE and PD #08-20-OPE.

FAIR HEARING IMPLICATIONS

Avoidance/ Ensure that all case actions are processed in accordance with current procedures and that electronic case files are kept up-to-date. Remember that participants must receive either adequate or timely and adequate notification of all actions taken on their case.

Resolution

Conferences If a participant comes to the FS Center and requests a conference,

the Receptionist must alert the Center Director’s designee that the participant is to be seen. If the participant contacts the Worker directly, advise the participant to call the Center Director’s designee. In Model Centers, the Receptionist at Main Reception will issue an NCA General ticket to the participant to route him/her to NCA FS Reception. The NCA FS Receptionist will issue a Conf/Appt/Problem ticket and verbally alert the FS Center Director’s designee.

The designee will listen to, evaluate and review the participant’s complaint regarding the FS case. The designee is responsible for ensuring that further appeal by the participant through a Fair Hearing request is properly controlled and that the appropriate follow-up action is taken in all phases of the Fair Hearing process.

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All conferences concerning the periodic reporting process will be handled at the participant’s Food Stamp Center. If the participant submits documentation during the conference that is sufficient to terminate a pending closing, the designee will image and index the Periodic Report and any documentation submitted and process an action to SIC the case.

Evidence Packets For Fair Hearing purposes, all evidence packets must contain a copy

of the Periodic Report and any other documentation submitted by the participant in order to help support the Agency’s action. Food Stamp Source BookREFERENCES (FSSB), pages 302-310 01-ADM 0901-ADM 1402-ADM 0704-ADM 0207-ADM 057 CFR 273.12(a) (5) 18 NYCRR 387.17 (d) and (e) GIS 01 TA/DC010GIS 04 TA/DC018 PB #04-105-ELIRELATED ITEMS PB #08-01-ELI PB #08-13-OPE

ICPWeb Instructions ATTACHMENTS Attachment A

Food Stamp Periodic Report (Rev. 4/07) LDSS-4310 Please use Print on

Demand to obtain copies of forms.

Follow-Up to the Periodic Report (Rev. 4/07) LDSS-4310A Important Information About What Changes You Must Report For Food Stamps (Rev. 2/03)

LDSS-4791

NYSNIP Food Stamp Benefits Interim Report (NYC) (Rev. 11/11)

LDSS-4836 NYC

Notice of Documentation Required – Change in Household Circumstances (Rev. 3/8/12)

W-132S

Notice of Documentation Required – Change in Household Circumstances (Spanish)

W-132S (S)

(Rev. 3/8/12)

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Attachment A

ICPWeb Instructions

Sign onto the HRA Intranet and select “Web Program Applications”.

Select Web Program Applications

On the Web Based Applications page select “Income Clearance Program (ICP web) – Production”.

Select Income Clearance Program (ICP web) – Production

Attachment A After you have scanned a Periodic Mailer or a batch of Periodic Mailers, select SCAN & INDEX.

Select SCAN & INDEX

The Periodic Mailer(s) that you have scanned will appear in your scan and index folder. Select the case number of the Periodic Report that you are ready to index (and data enter) into the ICPWeb. After selecting the case number, click on “Proceed to Next Screen”.

Select the case number of the Periodic Report that you are ready to index.

Select Proceed to Next Screen after selecting the case number.

Attachment A Select the pages belonging to a document and then click “add selected pages to document”.

Select add selected pages to document

Select the page number of the document.

Select Proceed to Next Screen.

On the right hand side of the screen you will see the documents that were just created. In the screenshot below, 2 documents were created. Select “Proceed to Next Screen”.

2 documents were created.

Select Proceed to Next Screen.

Attachment A The case number appears. Click Search and match the details with the Periodic Report to make sure that it was scanned under the correct case number.

Click Search.

The case number and demographic data come up. Click on search and match the details with the Periodic Report to make sure it is scanned under the correct case number. Select the document type and then click “Preview” to see the document in the Preview field. After the documents have been checked, click “Next”.

Select the Document Type

Click Next

Attachment A Determine if the Periodic Report is complete, incomplete, or undelivered and make the appropriate selection. If the Periodic Report is unsigned, select Incomplete.

Select Complete, Incomplete, or Undelivered.

If Incomplete is selected, the statement Reasons for Incomplete will appear. Select Incomplete Signature if the report is unsigned or Incomplete Questionnaire if the report is incomplete. If the report is both unsigned and incomplete, select Incomplete Signature.

If the Periodic Report is incomplete or unsigned select Incomplete.

In the drop down line select Incomplete Questionnaire or Incomplete Signature.

Attachment A If Undelivered is selected, the case address on the report and the WMS address will appear. Answer the question Is case address and WMS address different. If different select Yes, if the address is the same select No.

Select Yes if the addresses are different, No if the addresses are the same.

If Complete is selected, click “Yes” if there are no changes and no enclosed documentation and select “No” if there are any changes and/or any enclosed documentation.

Select Yes or No.

Attachment A Data enter the information listed on Sections 1 and 2 of the Periodic Report onto the corresponding location on the ICPWeb page.

Enter Section 1data.

Enter Section 2 data

LDSS-4310 (Rev. 4/07)

Periodic Report LDSS ADDRESS CITY, STATE ZIP

You must fill out this Report and return it to the address listed on the back by REPORT DUE DATE to continue getting benefits.

WHEN YOU RETURN THIS REPORT, MAKE SURE THAT THE LOCAL DISTRICT ADDRESS ON THE BACK OF THIS REPORT SHOWS IN THE RETURN ENVELOPE WINDOW.

CASE NAME ADDRESS CITY, STATE ZIP

This “Periodic Report” helps us to gather information about any changes you may have had since the last time you were in contact with your eligibility worker. Please make sure to read and follow all the instructions before filling out this “Periodic Report”. It is important for you to complete, sign and return this “Periodic Report” by the due date listed above. Failure to do so may result in your Child Assistance (CAP), Child Care, and/or Food Stamp Benefits being discontinued. CASE NAME

CASE NAME CASE NUMBER

CASE NUMBER OFFICE

OFFICE UNIT

UNIT WORKER

WORKER

If you have any questions on how to fill out this Report, call :( ) PHONE NUMBER

We must get your completed Report by REPORT DUE DATE. If we don’t get the completed Report by this date, your Child Assistance (CAP), Child Care and/or Food Stamp Benefits will stop. Failure to return this report will not affect your Medicaid coverage.

General Instructions

1. You must answer all questions on this Report. Answer all questions on this Report for everyone who is getting, or anyone who is legally responsible for someone getting, Child Assistance (CAP), Child Care, and/or Food Stamp Benefits.

2. Do not sign this Report any sooner than SIGNATURE DATE. If you do, this report is not considered complete.

3. You must complete this Report and return it to the address on the back of this report by REPORT DUE DATE, or your Child Assistance (CAP), Child Care or Food Stamp Benefits may be reduced or closed.

Reminder: If you are also receiving Temporary Assistance and Medicaid, you must report any changes to your worker within 10 days. For Food Stamp Benefits, you must report within ten days after the end of the month if your total monthly gross income exceeds the 130% limit you have been given. Otherwise, you do not need to report changes at any time other than on this Periodic Report or at Recertification, whichever occurs first. You must contact your worker immediately if any changes occur that affect your Child Care.

LDSS-4310 (Rev. 4/07)

SECTION 1: Please list ALL income for EACH household member. If you are only receiving food stamp benefits, you only have to list earnings here for each household member who works. (Examples of income include earnings from a job, Unemployment Insurance, Social Security Benefits, Supplemental Security Income [SSI])

Who Name of Employer or Other

Source of Income How Often?

(Daily, Weekly, Bi-Weekly, Monthly)

Total # of Hours Worked Per Week REPORT MONTH

Send in proof of all income that any household member got during the entire month of REPORT MONTH. If CAP INDICATOR IS PRESENT, THE FOLLOWING SENTENCE WILL REPLACE THE SENTENCE ABOVE: Since you participate in the Child Assistance Program (CAP), send proof of earnings, other income, and child care costs for 1ST Month of Report Qtr, 2ND Month of Report Qtr, and 3RD Month of Report Qtr.

SECTION 2: Have there been any other changes (read boxes below) since your last Report, or do you expect any changes?

No □ or Yes □ If Yes, you must check (√) at least one of the boxes below.

□ Your household moved (Write the new address below.) □ Someone moved into or out of your household (Write who moved and when and new amount of rent.) □ Your rent went up or down (Write new rent amount.) □ Someone started or left work (Write who, when, and where they started or left work.) □ Someone had a change in the amount of their unearned income. □ our child care costs or child care provider changed (Write new amount and who provides the child care.) Y□ Your need for child care has changed due to a change in your work schedule or other reason. (Explain what has changed) □ A change in contribution or subsidy (Write what the contribution is and new amount.) □ Someone is pregnant (Write who and expected delivery date, if known.) □ Death or Birth of someone in the household (Write who and when.) □ hange in legally obligated child support paid by a member of your household (Write who in your household pays the support.) C□ Other changes that may affect benefits (Write who, what, and when change occurred and give proof, if possible.) Write the details of your change(s) here, and if you have proof send it in:

CERTIFICATION: I understand that the information I provide on this report may result in changes in my assistance, including reducing the amount of my Temporary Assistance Benefits, Food Stamp Benefits, Child Care Benefits or closing my case. I am aware that Federal and State Law provide for fine and/or imprisonment of any person who fraudulently attempts to receive, or fraudulently receives Temporary Assistance, Medicaid, Child Care or Food Stamp Benefits to which the person is not entitled. Information reported on this form may affect my eligibility for Medicaid. I understand that I must contact my worker to report any changes that occur for my Temporary Assistance and Medicaid case within 10 days. I understand that I must contact my worker immediately if any changes occur that affects my child care. I also understand that if I use a child care provider who is not licensed or registered, my provider must meet certain requirements in order to be paid. For my Food Stamp Benefits case, I must report changes on the Periodic Report and at Recertification, whichever occurs first. I may also report changes at any other time. IMPORTANT- YOU MUST SIGN AND DATE THIS FORM NO SOONER THAN SIGNATURE DATE. IF YOU CHECKED “YES” TO ANY CHANGES IN SECTION 2, MAKE SURE YOU CHECKED (√) THE BOX(ES) AND GAVE MORE DETAIL. IF THIS REPORT IS NOT COMPLETE, WE WILL SEND YOU A DISCONTINUANCE NOTICE.

Your Signature: Date: Telephone Number (daytime)

Fill Out & Return In The Envelope Provided LDSS OFF/UNIT/WKR ADDRESS ADDRESS CITY, STATE ZIP

When you return this Report, make sure you can see this address in the return envelope window

LDSS-4310A (Rev. 4/07)

FOLLOW-UP TO THE PERIODIC REPORT CASE NAME CASE NUMBER OFFICE/ UNIT NUMBER

WORKER NUMBER

WORKER NAME (CASELOAD)

If you have any questions on how to fill out this Report, call:

We must get your completed Report by ___________________. If we don’t get the completed Report by this date, your Child Assistance (CAP), Child Care and/or Food Stamp Benefits will stop. Failure to return this report will not affect your Medicaid coverage.

General Instructions 1. You must answer all questions on this Report. Answer all questions on this Report for everyone who is

getting, or anyone who is legally responsible for someone getting, Child Assistance (CAP), Child Care, and/or Food Stamp Benefits.

2. Do not sign this Report any sooner than ________________. If you do, this report is not considered complete.

3. You must complete this Report and return it to the address on the front of the enclosed notice by _______________, or your Child Assistance (CAP), Child Care or Food Stamp Benefits may be reduced or closed.

Reminder: If you are also receiving Temporary Assistance and Medicaid, you must report any changes to your worker within 10 days. For Food Stamp Benefits, you must report within ten days after the end of the month if your total monthly gross income exceeds the 130% limit you have been given. Otherwise, you do not need to report changes at any time other than on this Periodic Report or at Recertification, whichever occurs first. You must contact your worker immediately if any changes occur that affect your Child Care.

SECTION 1: Please list ALL income for EACH household member. If you are only receiving food stamp benefits, you only have to list earnings here for each household member who works.

(Examples of income include earnings from a job, Unemployment Insurance, Social Security Benefits, Supplemental Security Income [SSI])

Who Name of Employer or Other Source of Income

How Often? (Daily, Weekly,

Bi-Weekly Monthly,)

Total # of Hours Worked Per Week

“Report Month”

Send in proof of all income that any household member got during the entire month of

_____________. (Report Month)

Child Assistance Program (CAP) cases must send in proof of earnings, other income, and child care costs for the months of _____________, _____________, and ______________. (Report Quarter)

LDSS-4310A (Rev. 4/07) REVERSE

SECTION 2: Have there been any other changes (read boxes below) since your last Report, or do you expect any changes?

No □ or Yes □ If Yes, you must check (√) at least one of the boxes below. □

Someone moved into or out of your household (Write who moved and when and new amount of rent.) Your household moved (Write the new address below.)

□our rent went up or down (Write new rent amount.) □ Y

Someone started or left work (Write who, when, and where they started or left work.) □ Someone had a change in the amount of their unearned income. □

□ Your child care costs or child care provider changed (Write new amount and who provides the child care.)

□ Your need for child care has changed due to a change in your work schedule or other reason. (Explain what has changed) A change in contribution or subsidy (Write what the contribution is and new amount.) □

Someone is pregnant (Write who and expected delivery date, if known.) □ Death or Birth of someone in the household (Write who and when.) □

□ Change in legally obligated child support paid by a member of your household (Write who in your household pays the support.)

□ Other changes that may affect benefits (Write who, what, and when change occurred and give proof, if possible.) Write the details of your change(s) here, and if you have proof send it in:

CERTIFICATION: I understand that the information I provide on this report may result in changes in my assistance, including reducing the amount of my Temporary Assistance Benefits, Food Stamp Benefits, Child Care Benefits or closing my case. I am aware that Federal and State Law provide for fine and/or imprisonment of any person who fraudulently attempts to receive, or fraudulently receives Temporary Assistance, Medicaid, Child Care or Food Stamp Benefits to which the person is not entitled. Information reported on this form may affect my eligibility for Medicaid. I understand that I must contact my worker to report any changes that occur for my Temporary Assistance and Medicaid case within 10 days. I understand that I must contact my worker immediately if any changes occur that affects my child care. I also understand that if I use a child care provider who is not licensed or registered, my provider must meet certain requirements in order to be paid. For my Food Stamp Benefits case, I must report changes on the Periodic Report and at Recertification, whichever occurs first. I may also report changes at any other time. IMPORTANT- YOU MUST SIGN AND DATE THIS FORM NO SOONER THAN ___________________. IF YOU CHECKED “YES” TO ANY CHANGES IN SECTION 2, MAKE SURE YOU CHECKED (√) THE BOX(ES) AND GAVE MORE DETAIL. IF THIS REPORT IS NOT COMPLETED, WE WILL SEND YOU A DISCONTINUANCE NOTICE.

Your Signature:

Date: Telephone Number (daytime)

LDSS-4791 (Rev. 2/03)

IMPORTANT INFORMATION ABOUT WHAT CHANGES YOU MUST REPORT FOR FOOD STAMPS

Esta carta está traducida al español en la página 2

General Telephone No. for Questions or Help: ___________________________ New Food Stamp Program rules make it easier for households with income to report changes that may affect eligibility or benefit levels. As a household with income, you are only required to report changes about your Food Stamp household at the time of your next recertification, with two exceptions: If your household’s gross monthly income is more than $____________ (130% of the poverty level) you must report this monthly amount to your social services district by phone, in writing, or in person within 10 days after the end of the month. Gross income is the amount of income before taxes and other deductions are taken out, not the amount you receive when you cash your check. We must use the gross income in figuring your eligibility for food stamps. Any income that you receive must be added together to know if you are over 130% of the poverty level. Examples of income that count include earnings, child support payments, Unemployment Insurance, temporary assistance payments, Workers Compensation or disability payments such as Social Security, SSI or private disability payments. For example, if your only income is from earnings, you are paid weekly and your gross income is over $ ___________ a week, or if you are paid biweekly and your gross income is over $______________ biweekly, you must report this to us within 10 days after the end of the month. When you add up your earnings, to see if you are over 130% of poverty, use your gross pay from the last four weeks of the month. If you are an Able-Bodied Adult Without Dependents (“ABAWD”), you must tell us if your work hours go below 80 hours a month. You must tell us this within 10 days after the end of the month when your work hours fell below 80 hours. If you have a six-month certification period, any other changes to your Food Stamp household including who lives with you, rent costs, and gross income changes under 130% of the poverty level do not need to be reported until your next six-month recertification. If you only report once a year for recertification (12 month certification period), and do not receive Temporary Assistance, you will be required to report your changes on one mail report received 6 months into your certification period. You may still voluntarily report any change about your household and, if this change will increase your benefit level and you verify this change, we will increase your benefit. These changes apply only to the Food Stamp Program. If you also receive Temporary Assistance (TA), you are still required to report changes for TA within 10 days of the change. If you have questions about this new reporting requirement, or if your gross income exceeds the 130% poverty level printed above, you may call the number printed at the top of this letter. Otherwise you will be required to recertify at your next scheduled recertification date and can report any changes you have at that time.

LDSS-4791-SP (Rev. 2/03) REVERSO

INFORMACIÓN IMPORTANTE SOBRE LOS CAMBIOS QUE USTED DEBE REPORTAR COMO BENEFICIARIO DE CUPONES DE ALIMENTOS

No. de teléfono general para hacer preguntas o pedir ayuda: _________________________

Nuevas reglas relacionadas al Programa de Cupones de Alimentos facilitan a hogares con ingresos el reportar cambios que afectan los requisitos necesarios para obtener cupones de alimentos o la cantidad de beneficios que el hogar recibe. Si su hogar es un hogar que recibe ingresos, solamente se le requiere que reporte cambios pertinentes a al hogar que recibe beneficios de Cupones de Alimentos cuando presenta una recertificación, con dos excepciones: Si el ingreso mensual bruto de su hogar excede $____________ (130% del nivel de pobreza), usted debe reportar esta cantidad mensual a su distrito de servicios sociales por teléfono, por escrito, o en persona, dentro de 10 días de finalizar el mes. El ingreso bruto es la cantidad de ingresos antes de pagar impuestos y descontar otras deducciones y no la cantidad que usted recibe cuando cobra su cheque. Nosotros debemos utilizar el ingreso bruto al calcular si usted reúne o no los requisitos para recibir Cupones de Alimentos.

Cualquier otro ingreso que usted reciba debe ser agregado al ingreso total para determinar si usted sobrepasa el 130% del nivel de pobreza. Ejemplos de ingresos que tomamos en cuenta incluyen: ingresos, pagos de manutención infantil, seguro por desempleo, pagos de asistencia temporal, compensación laboral o pagos por incapacidad, tales como los del Seguro Social, SSI o pagos privados por incapacidad. Por ejemplo, si su único ingreso proviene de ingresos, si se le paga semanalmente, y si su ingreso bruto excede $__________ por semana, o si a usted se le paga cada dos semanas y su ingreso bruto excede $__________ cada dos semanas, usted nos debe reportar esto dentro de 10 días de finalizar el mes. Cuando usted suma sus ingresos para determinar si sobrepasa el 130% del nivel de pobreza, utilice el salario en bruto recibido en las últimas cuatro semanas del mes. Si usted es un Adulto Capaz de Trabajar sin Dependientes (Able-Bodied Adult Without Dependents—ABAWD), usted nos tiene que informar si sus horas de trabajo se reducen a menos de 80 horas al mes. Usted nos debe informar esto dentro de 10 días contados a partir del fin del mes en el cual sus horas de trabajo disminuyeron a menos de 80 horas de trabajo. Si usted tiene una certificación por un período de seis meses, cualquier otro cambio que se efectúe en el hogar que recibe Cupones de Alimentos, incluyendo las personas que viven con usted, costos de alquiler, y cambios en los ingresos brutos inferiores al 130% del nivel de pobreza, no necesitan ser reportados hasta su próxima recertificación de los seis meses. Si su período de recertificación es de solamente una vez al año (certificación por un período de 12 meses), y no recibe Asistencia Temporal a usted se le exigirá reportar sus cambios en un informe por correo que recibirá cumplidos los seis meses de su período de certificación. Usted todavía puede reportar voluntariamente cualquier cambio acerca de su hogar, y, si este cambio va a incrementar su nivel de beneficios y usted verifica este cambio, nosotros aumentaremos su beneficio. Estos cambios solamente se aplican al Programa de Cupones de Alimentos. Si usted también recibe Asistencia Temporal (TA) todavía se le requiere reportar cambios pertinentes a la asistencia de TA dentro de 10 días de efectuarse el cambio. Si tiene alguna pregunta acerca de este nuevo requisito de reporte, o si su ingreso bruto excede el 130% del nivel de pobreza indicado anteriormente, usted puede llamar al número de teléfono impreso en la parte superior de esta carta. De lo contrario, usted tendrá que presentar una recertificación durante su próxima cita de recertificación y podrá reportar cualquier cambio que tenga en ese momento.

LDSS-4836 NYC (Rev 11/11) New York State Office of Temporary and Disability Assistance

NYSNIP Food Stamp Benefits Interim Report (NYC)

Notice Date:___________________________

Due Date:_____________________________

Please fill out this form right away and return it to the address listed above. If you don’t send the form back, we will have to stop your food stamp benefits. We’ve sent this form because we must update your NYSNIP food stamp benefits case. The law says we must do this every two years. Please answer the questions below about your housing and utility expenses. These expenses affect how much you can get in food stamps. If you never told us about your housing and utility costs, or if these costs have gone up, we might be able to give you more food stamps.

Even if you have no changes to report, you must send the form back or your food stamp benefits will stop. Please sign and date the form and return it to us no later than the 10th day of next month. You can respond by calling the SSI-FS Center Helpline at 718-722-4009.

QUESTIONS YOU MUST ANSWER

1. Do you pay more than $235 each month for rent or for mortgage payments, taxes and insurance on your property?□ Yes □ No

If you answered “Yes”, and have never sent us proof of these expenses, attach the proof now – such as a rent receipt, landlord statement, mortgage payment, cancelled check or money order.

2. Do you live in either public or subsidized housing where heat is included in your rent? □ Yes □ No

3. Answer this question ONLY if you live in public or subsidized housing AND heat is included in your rent: a. Do you pay a monthly excess charge to your landlord for air conditioning? □ Yes □ No

b. Do you pay an electric bill and use an air conditioner? □ Yes □ No (If you answered “Yes” to either a. or b., and have never sent us proof of these expenses, attach the proof now – such as an electric bill, landlord statement, or canceled check or money order.

APPLICANT’S SIGNATURE

X

DATE SIGNED

IMPORTANT INFORMATION

YOU MAY BE ENTITLED TO HIGHER BENEFITS

The maximum monthly Food Stamp Benefit for one person is $200. If you are receiving less than this amount, you MAY be eligible for higher benefits, especially if ANY of the following applies to you:

You have more than $35 each month in unreimbursed medical expenses, that is, medical expenses that you yourself must pay and that are not paid by Medicare, Medicaid, or any other health insurance.

Your rent is more than $425 per month. If your monthly income decreases by $75 or more due to a reduction of your SSI grant.

If you have any of these circumstances and want to find out whether you might be able to get more Food Stamp Benefits or if you have questions about how to fill out this form, call the SSI-FS Center Helpline at 718-722-4009 or call the State Food Stamp Hotline at 1-800-342-3009. Thank you.

Make sure to return this report to the address listed above.

We are pleased that you participate in the Food Stamp Program and would like for you to continue to participate.

Remember, you can respond to this report by calling the SSI-FS Center Helpline at 718-722-4009.

fold

Please verify:

Form W-132S LLF Rev. 3/8/12

Date:

Case Number:

Case Name:

NCA FS Center:

Notice of Documentation Required – Change in Household Circumstances

Under food stamp rules, you must verify changes in your circumstances that entitle you to increased benefits. You recently reported such a change to us, but you did not verify the change. We cannot increase your benefits until you do so. We have enclosed the Eligibility Factors and Suggested Documentation Guide (W-119D) that gives examples of documents you can use to verify the change you reported. Photocopies are acceptable. Send the required documentation in the enclosed self-addressed envelope right away so that your benefits are increased as soon as possible.

Income received by: gfedc

Presence in your household of: gfedc

Shelter expenses (e.g., rent or mortgage payments): gfedc

Child care or dependent care costs: gfedc

Medical expenses of: gfedc

Alien status of: gfedc

Other/Remarks: gfedc

Worker's Signature Date

Favor de comprobar:

Form W-132S (S) LLF Rev. 3/8/12

Fecha:

Número del Caso:

Nombre del Caso:Centro de

Cupones de Alimentos NCA:

Notificación de Documentación Solicitada – Cambio de Circunstancias en el Hogar

Conforme a las reglas de cupones para alimentos, usted tiene que comprobar cambios en sus circunstancias que le dan derecho a un aumento de beneficios. Recientemente usted nos informó de tal cambio, pero no comprobó el cambio. No podemos aumentarle sus beneficios hasta que usted así lo haga. Hemos adjuntado la Guía de Factores de Elegibilidad y Documentación Sugerida (W-119D [S]), que tiene ejemplos de documentos que puede usar para comprobar el cambio que reportó. Las fotocopias son aceptables. Envíenos de inmediato la documentación solicitada en el sobre adjunto con dirección del remitente para que podamos aumentarle sus beneficios tan pronto posible.

Ingreso recibido por: gfedc

Residen en su hogar: gfedc

Gastos de alojamiento (p.ej., pagos de alquiler o hipoteca): gfedc

Gastos de Cuidado Infantil o de dependientes: gfedc

Gastos médicos de: gfedc

Estado de extranjero de: gfedc

Otro/comentarios: gfedc

Firma del Trabajador Fecha