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OCFS-LDSS-4779 (Rev. 01/2013)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

APPROVAL OF YOUR APPLICATION FOR CHILD CARE BENEFITS NOTICE

DATE:

EFFECTIVE DATE

NAME AND ADDRESS OF AGENCY/CENTER OR DISTRICT OFFICE

CASE NUMBER

CIN NUMBER

CASE NAME (And C/O Name if Present) AND ADDRESS

GENERAL TELEPHONE NO. FOR

QUESTIONS OR HELP

OR Agency Conference

Fair Hearing information and assistance

Record Access

Legal Assistance Information

nformation

OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

WORKER TELEPHONE NO.

Your application dated for child care benefits has been approved.

Your child care benefits are effective* to* while you are .

Comments:

BENEFITS. Payment will be provided on behalf of the following:

Child(ren): For this provider: For the amount of:** Full Time or Part Time:

*Note: “effective” means the action or benefit begins on that day, “to” means the action or benefit is in effect on that date.

**Payment may vary based on fluctuations in your approved activity and/or absences. Benefits will be paid: Directly to you. Directly to your provider.

Your provider must submit a monthly bill and attendance sheet.

FAMILY SHARE. You are responsible for paying the following fees:

Effective , a Weekly Family Share must be paid to

in the amount of $ per week.

Effective , an Additional Family Share must be paid to


Effective , a Court Ordered Family Share must be paid to

in the amount of $ per week, for the child(ren) .

The following information is an explanation of how your weekly family share was determined.

Family’s annual gross income

St

$

Minus 100% annual state income standard for a family size of $

Remaining income $

Remaining income $ X family share % %

% = $

$ / 52 weeks = $ weekly family share

All family share amounts are rounded to the nearest $0.50. There is a minimum fee of $1 per week for all families not receiving TA.

In order to continue to receive benefits these are your responsibilities:

Notify your caseworker immediately of any change in family income, who lives in your house, employment, child care arrangements or other changes which may affect your continued eligibility or the amount of your benefit.

Promptly pay any family share required.

YOU HAVE THE RIGHT TO APPEAL THIS DECISION.

BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO APPEAL THIS DECISION

CLIENT/FAIR HEARINGS COPY

OCFS-LDSS-4779 (Rev. 01/2013) Reverse

RIGHT TO REJECT SERVICES: Approval of your application does not obligate you to accept the services. You may choose to

decline the services.

RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one

as soon as possible. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we

determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling us

at the number on the front of this notice or by sending a written request to us at the address listed at the top of the first page of this

notice. This number is used only for asking for a conference. It is not the way you request a fair hearing.

If you ask for a conference you are still entitled to a fair hearing. Requesting an agency conference does not affect your right

to also request a fair hearing. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by:

(1) Telephoning: (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL) 1-800-342-3334. OR

(2) Writing: Complete the information below, sign and mail to the New York State Office of Administrative Hearings, Office of

Temporary and Disability Assistance, P.O. Box 1930, Albany, New York, 12201-1930. Please keep a copy for yourself. OR

(3) FAX: Complete the information, sign and fax both sides of this form for your fair hearing request to (518) 473-6735. OR

(4) Online: To send your fair hearing request online, go to http://www.otda.ny.gov/oah, click on the links to request a fair hearing

using the online form, and follow the instructions to complete and submit the form online.

YOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING

If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to

be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other

representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well

as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor.

You should bring to the hearing any documents such as this notice, pay-stubs, receipts, child care bills, medical verification, letters, etc.

that may be helpful in presenting your case.

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid

Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages

under “Lawyers” or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your

case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing

officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number

listed at the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice. Also, if you call or write

to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you

want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable

time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get

additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address

printed at the top of page 1 of this notice.

REQUEST FOR A FAIR HEARING

I want a fair hearing. I do not agree with the agency’s action. (You may explain why you disagree below, but you do not have to

include a written explanation.)

Name: District:

Address: Case Number:

Telephone:

http://www.otda.ny.gov/oah

OCFS-LDSS-4780 (Rev. 01/2013)

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

DENIAL OF YOUR APPLICATION FOR CHILD CARE BENEFITS NOTICE

DATE:

EFFECTIVE DATE


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



Record Access

Legal Assistance information

OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


Your application dated has been denied and the reason or reasons your application has been

denied are explained below.

Comments:

You are ineligible to receive benefits because:

Your monthly gross income of $ for a family size of exceeds 200% of the

State Income Standard of $ , which is the maximum monthly gross income allowed by New York

State regulation to be eligible for child care subsidy. (Please see the attached addendum for additional information)

You have not provided us with the following documents:

You are not programmatically eligible for child care services because:

Due to insufficient funding the district is not opening cases at this time.

Due to insufficient funding, the district is only opening cases up to % of the State Income Standard.

Your family’s monthly gross income of

Your family’s monthly gross income is

$ exceeds the maximum monthly gross income of

$ for your family size. Also, your family does not meet the eligibility criteria for a child care

guarantee designation. (Please see attached addendum for additional information)

Other:

The LAW(S) AND/OR REGULATION(S) that allows us to do this is:


BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO APPEAL THIS DECISION CLIENT/FAIR HEARINGS COPY

OCFS-LDSS-4780 (Rev. 01/2013) REVERSE

RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as soon as possible. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling us at the number on the front of this notice or by sending a written request to us at the address listed at the top of the first page of this notice. This number is used only for asking for a conference. It is not the way you request a fair hearing. If you ask for a conference you are still entitled to a fair hearing. A request for a conference alone will not result in continuation of benefits. Requesting an agency conference does not affect your right to also request a fair hearing. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by: (1) Telephoning: (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL) 1-800-342-3334. OR (2) Writing: Complete the information below, sign and mail to the New York State Office of Administrative Hearings, Office of

Temporary and Disability Assistance, P.O. Box 1930, Albany, New York, 12201-1930. Please keep a copy for yourself. OR (3) FAX: Complete the information, sign and fax both sides of this form for your fair hearing request to (518) 473-6735. OR




If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay-stubs, receipts, child care bills, medical verification, letters, etc. that may be helpful in presenting your case.

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address printed at the top of page 1 of this notice.


I want a fair hearing. I do not agree with the agency’s action. (You may explain why you disagree below, but you do not have to include a written explanation.)

Name: District:


Telephone:


OCFS-LDSS-4780 (Rev. 01/2013) Page 2

ADDENDUM TO DENIAL OF YOUR APPLICATION

FOR CHILD CARE BENEFITS-FINANCIAL ELIGIBILITY CALCULATION

Effective Date:

Case Name: Case Number:

We have determined that you are not eligible for child care benefits. Your family’s monthly gross income is $ .

This exceeds the maximum monthly gross income standard of $ for a family size of .

Please check the information below. If there is a mistake contact your caseworker listed on page one of this notice. If there is a

mistake, it could mean that the decision made about your benefits is not correct.

There is a child with special needs residing in your household. Yes No If you have a child with special needs, that needs child

care, you may have received this notice in error. Contact your caseworker on page one of this notice to determine if you were

denied child care benefits in error.

Your family’s monthly gross income was determined from the following sources:

Wages or salary (18 NYCRR § 404.5(b)(5)(i)) before taxes in the amount of: $ per month.

Social Security (18 NYCRR §404.5(b)(5)(iv)) in the amount of: $ per month.

Child Support (18 NYCRR §404.5(b)(5)(xi)) in the amount of: $ per month.

*Other income not listed above as defined in New York State regulation

18 NYCRR §404.5(b)(5) in the amount of: $ per month.

Your family’s total monthly gross income: $ per month.

The following information is an explanation of how your eligibility for child care benefits was determined. To determine eligibility for child

care benefits, your family’s monthly gross income for your family size was compared to the Social Service District’s (SSD) priority level for

the monthly income standard. For a family to be eligible for child care benefits, a family must make less than the Monthly Income

Standard amount listed below for their family size. Below are the Monthly Income Standards used by the district to determine your

eligibility for child care benefits.

Family Size SSD’s Priority Level = %

Monthly Income Standard

1

2

3

4

5

6

7

8

For families with more than 8 persons, add $330 for each additional person.

Your family’s monthly gross income is $ for a family size of . This exceeds the maximum of $ .

*Other income not listed above and defined in New York State regulation 18 NYCRR 404.5(b)(5) are defined as but not limited to the

following: net income for non-farm self-employment, i.e. gross receipts minus expenses from one’s own business, professional

enterprise or partnership; or net income from farm self-employment, i.e. gross receipts minus operation expenses from the operation of a

firm by a person on his own account, as owner, renter or sharecropper; or dividends, interest (on savings or bonds) income from estates

or trusts, net rental income or royalties; public assistance (PA) or welfare payments include PA payments such as SSI and home relief;

or pensions and annuities include pensions or retirement benefits paid to a retired person or his survivors; or unemployment

compensation, workers’ compensation; or alimony; or veterans’ pensions.

In addition to the citations listed on the attached notice refer to the district’s Child and Family Services Plan, at

http://ocfs.ny.gov/main/childcare/plans/plans.asp for additional information on how the district closes cases in the event that there are

insufficient funds to provide child care benefits to all eligible families and the order in which they will open new cases should funding

become available.

http://ocfs.ny.gov/main/childcare/plans/plans.asp

OCFS-LDSS-4781 (Rev. 01/2013)


NOTICE OF INTENT TO CHANGE CHILD CARE BENEFITS AND FAMILY SHARE PAYMENTS NOTICE

DATE:

EFFECTIVE DATE


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


This notice is to inform you that this agency intends to change your Child Care benefits.

The changes are:

Comments:

BENEFITS:

Child(ren): For this provider: For the amount of:* Full Time or Part Time:

*Payment may vary based on fluctuations in your approved activity and/or absences.

FAMILY SHARE. You are responsible for paying the following fees:

Effective , a Weekly Family Share must be paid to


Effective , an Additional Family Share must be paid to


Effective , a Court Ordered Family Share must be paid to

in the amount of $ per week, for the child(ren)

. The following information is an explanation of how your weekly family share was determined.

Family’s annual gross income

St

$

Minus 100% annual state income standard for a family size of $

Remaining income $

Remaining income $ X family share % % = $

$ / 52 weeks = $ weekly family share.

All family share amounts are rounded to the nearest $0.50. There is a minimum fee of $1 per week for all families not receiving TA.

The reason for this action is:





OCFS-LDSS-4781 (Rev.01/2013) Reverse

RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as soon as possible. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling us at the number on the front of this notice or by sending a written request to us at the address listed at the top of the first page of this notice. This number is used only for asking for a conference. It is not the way you request a fair hearing. If you ask for a conference you are still entitled to a fair hearing. If you want to have your benefits continue unchanged (aid continuing) until you get a fair hearing decision, you must request a fair hearing in the way described below. A request for a conference alone will not result in continuation of benefits. Requesting an agency conference does not affect your right to also request a fair hearing. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by: (1) Telephoning: (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL) 1-800-342-3334. OR (2) Writing: Complete the information below, sign and mail to the New York State Office of Administrative Hearings, Office of

Temporary and Disability Assistance, P.O. Box 1930, Albany, New York, 12201-1930. Please keep a copy for yourself. OR (3) FAX: Complete the information, sign and fax both sides of this form for your fair hearing request to (518) 473-6735. OR




If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay-stubs, receipts, child care bills, medical verification, letters, etc. that may be helpful in presenting your case. Check one:

KEEP MY CHILD CARE BENEFITS THE SAME. If you request a fair hearing before the effective date of this notice, your child care benefits will be reinstated and will be unchanged until the fair hearing decision is issued. However, if you lose the fair hearing, you will owe any child care benefits that you should not have received. We are required to recover any child care overpayments. We must make a claim against you for any child care benefits you receive that you were not entitled to, which may be collected by reduction of future child care allotments, lump sum installment payments, or through legal action. If you want to avoid this possibility you can check the box below. You can also indicate over the telephone or in a letter that you do not want reinstatement of your child care benefits.

I do not want my child care benefits continued until the hearing decision is issued.

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice.


I want a fair hearing. I do not agree with the agency’s action. (You may explain why you disagree below, but you do not have to include a written explanation.)

Name: District:


Telephone:


OCFS-LDSS-4781 (Rev.01/2013) Page 2

ADDENDUM TO NOTICE OF INTENT TO CHANGE CHILD CARE BENEFITS AND

FAMILY SHARE PAYMENTS-FINANCIAL ELIGIBILITY CALCULATION

Effective Date:

Case Name:

Case Number:

The amount that you pay for your family share has changed from to

Below are the sources of income used to calculate your family’s income and the calculation used to determine your family

share.

Please check the information below. If there is a mistake contact your caseworker listed on page one of this notice.








The following information is an explanation of how your weekly family share was determined.

Family’s total monthly gross income $ X 12 months = $ Annual Income

Family’s annual gross income $

Minus 100% state income standard for a family size of $

Remaining income $

Remaining income $ X family share % % = $

$ / 52 weeks = $ weekly family share.

Family

Size

100% Annual State

Income Standard

1

2

3

4

5

6

7

8

For families with more than 8 persons, add $3,960 for each additional person.

*Other income not listed above and defined in New York State regulation 18 NYCRR 404.5(b)(5) are defined as but not limited to the

following: net income for non-farm self-employment, i.e. gross receipts minus expenses from one’s own business, professional

enterprise or partnership; or net income from farm self-employment, i.e. gross receipts minus operation expenses from the operation of a

firm by a person on his own account, as owner, renter or sharecropper; or dividends, interest (on savings or bonds) income from estates

or trusts, net rental income or royalties; public assistance (PA) or welfare payments include PA payments such as PA, SSI and home

relief; or pensions and annuities include pensions or retirement benefits paid to a retired person or his survivors; or unemployment

compensation, workers’ compensation; or alimony; or veterans’ pensions.

OCFS-LDSS-4782 (Rev. 01/2013) FRONT


NOTICE OF INTENT TO DISCONTINUE CHILD CARE BENEFITS

NOTICE

DATE:

EFFECTIVE DATE


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


This notice is to inform you that your case will be closed on .

You will no longer be receiving child care benefits beginning on .

Comments:

The reason for this action is:

Your monthly gross income of $ for a family size of exceeds 200% of the

State Income Standard of

$ , which is the maximum monthly gross income allowed by New York

State regulation to be eligible for child care subsidy. (Please see the attached addendum for additional information)

Due to insufficient funding, the district is closing cases at or above % of the State Income Standard.

Your family’s monthly gross income of $ exceeds the maximum monthly gross income of

$ for your family size. Also, your family does not meet the eligibility criteria for a child care

guarantee designation. (Please see the attached addendum for additional information)

You are not programmatically eligible for child care services because:

You did not provide the following documentation or the following documentation was not adequate:

Other





OCFS-LDSS-4782 (Rev. 01/2013) Reverse

RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as

soon as possible. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we

determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling us

at the number on the front of this notice or by sending a written request to us at the address listed at the top of the first page of this

notice. This number is used only for asking for a conference. It is not the way you request a fair hearing. If you ask for a

conference you are still entitled to a fair hearing. If you want to have your benefits continue unchanged (aid continuing) until

you get a fair hearing decision, you must request a fair hearing in the way described below. A request for a conference alone

will not result in continuation of benefits. Requesting an agency conference does not affect your right to also request a fair

hearing. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by:

(1) Telephoning: (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL) 1-800-342-3334. OR

(2) Writing: Complete the information below, sign and mail to the New York State Office of Administrative Hearings, Office of

Temporary and Disability Assistance, P.O. Box 1930, Albany, New York, 12201-1930. Please keep a copy for yourself. OR

(3) FAX: Complete the information, sign and fax both sides of this form for your fair hearing request to (518) 473-6735. OR




If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be

represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other

representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well

as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor.

You should bring to the hearing any documents such as this notice, pay-stubs, receipts, child care bills, medical verification, letters, etc.

that may be helpful in presenting your case.

Check One:

KEEP MY CHILD CARE BENEFITS THE SAME. If you request a fair hearing before your benefits end, your child care

benefits will be reinstated and will be unchanged until the fair hearing decision is issued. However, if you lose the fair hearing,

you will owe any child care benefits that you should not have received. We are required to recover any child care

overpayments. We must make a claim against you for any child care benefits you receive that you were not entitled to, which

may be collected by reduction of future child care allotments, lump sum installment payments, or through legal action. If you

want to avoid this possibility you can check the box below. You can also indicate over the telephone or in a letter that you do

not want reinstatement of your child care benefits.

I do not want my child care benefits continued until the hearing decision is issued.

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid

Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages

under “Lawyers” or by calling the number indicated on the first page of this notice

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case

file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer

at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at

the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice. Also, if you call or write to us, we

will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want

copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time

before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get

additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address

printed at the top of page 1 of this notice.


I want a fair hearing. I do not agree with the agency’s action. (You may explain why you disagree below, but you do not have to include

a written explanation.)

Name: District:


Telephone:


OCFS 4782 (Rev. 01/2013) Page 2

ADDENDUM TO NOTICE OF INTENT

TO DISCONTINUE CHILD CARE BENEFITS-FINANCIAL ELIGIBILITY CALCULATION

Effective Date:

Case Name: Case Number:

We have determined that you are no longer eligible for child care benefits. Your family’s monthly gross income is $ .

This exceeds the maximum monthly gross income standard of $ for a family size of .

Please check the information below. If there is a mistake contact your caseworker listed on page one of this notice. If there is a

mistake, it could mean that the decision made about your benefits is not correct.

There is a child with special needs residing in your household. Yes No If you have a child with special needs, that needs

child care, you may have received this notice in error. Contact your caseworker listed on page one of this notice to determine if

your case was closed in error.








The following information is an explanation of how your eligibility for child care benefits was determined. To determine eligibility for child

care benefits, your family’s monthly gross income for your family size was compared to the Social Service District’s (SSD) priority level for

the monthly income standard. For a family to be eligible for child care benefits, a family must make less than the Monthly Income

Standard amount listed below for their family size. Below are the Monthly Income Standards used by the district to determine your

eligibility for child care benefits.

Family Size SSD’s Priority level = %

Monthly Income Standard

1

2

3

4

5

6

7

8

For families with more than 8 persons, add $330 for each additional person.

Your family’s monthly gross income is $ for a family size of .

This exceeds the maximum income of $ .

*Other income not listed above and defined in New York State regulation 18NYCRR 404.5(b)(5) are defined as but not limited to the

following: net income for non-farm self-employment, i.e. gross receipts minus expenses from one’s own business, professional enterprise

or partnership; or net income from farm self-employment, i.e. gross receipts minus operation expenses from the operation of a firm by a

person on his own account, as owner, renter or sharecropper; or dividends, interest (on savings or bonds) income from estates or trusts,

net rental income or royalties, public assistance (PA) or welfare payments include PA payments such as PA, SSI and home relief; or

pensions and annuities include pensions or retirement benefits paid to a retired person or his survivors; or unemployment compensation,

workers’ compensation; or alimony; or veterans’ pensions.

In addition to the citations listed on the attached notice refer to the district’s Child and Family Services Plan, at

http://ocfs.ny.gov/main/childcare/plans/plans.asp for additional information on how the district closes cases in the event that there are

insufficient funds to provide child care benefits to all eligible families and the order in which they will open new cases should funding

become available.

http://ocfs.ny.gov/main/childcare/plans/plans.asp

OCFS-LDSS-4783 (Rev. 12/2004)


DELINQUENT FAMILY SHARE FOR CHILD CARE BENEFITS NOTICE DATE: NAME AND ADDRESS OF AGENCY/CENTER OR DISTRICT OFFICE

CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



Record Access

Legal Assistance

information

OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

TELEPHONE NO.

This notice is to tell you that you are delinquent in making payment of your family share of $ per

. The total amount overdue is $

. If the total amount overdue

has not been paid, or if a satisfactory arrangement to make payment of the amount overdue has not been made by

, this agency will take action to discontinue your Child Care benefits.

The Law(s) and/or Regulation(s) that allow us to do this is:

18 NYCRR Section 404.6(a) and 404.6(b)

You must pay the total amount overdue or make a satisfactory arrangement for payment of the overdue amount no later

than to avoid further action by this agency.

If you need to arrange a payment plan, contact:

Your overdue fees should be paid to:

FAILURE TO PAY FAMILY SHARE OR MEET THE REQUIREMENTS OF YOUR PAYMENT PLAN WILL LEAD TO

DISCONTINUANCE OF YOUR CHILD CARE BENEFITS.

Reviewed 1/2013

OCFS-LDSS-7009 (1/2005) FRONT


NOTICE OF CHILD CARE ASSISTANCE OVERPAYMENT AND REPAYMENT REQUIREMENTS

NOTICE DATE

CASE NUMBER:

CIN NUMBER:


GENERAL TELEPHONE NO. FOR QUESTIONS OR HELP


Fair Hearings Information and Assistance 1-800-342-3334

0BCASE Name (And C/O Name if Present) and ADDRESS

Record Access

Legal Assistance Information OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

TELEPHONE NO.

YOU HAVE THE RIGHT TO A FAIR HEARING TO APPEAL THIS DECISION. YOU ALSO HAVE THE RIGHT TO AN AGENCY CONFERENCE. BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO APPEAL THIS DECISION AT A FAIR HEARING AND/OR REQUEST AN AGENCY CONFERENCE.

1BSECTION I – NOTICE OF CHILD CARE ASSISTANCE OVERPAYMENT 2BYou received more child care benefits than you should have (overpayment) from 3B 4Bto

5B 6B. The amount of the overpayment is $ 7B 8B.

9BThe reason the overpayment occurred is:

You or someone in your household failed to inform us of changes that affect your eligibility or benefit level.

We incorrectly gave you more benefits than you should have gotten due to:

Other: 12B 13BExplanation and Calculation of Overpayment:

14BThe regulations that allow us to do this are 18 NYCRR 415.4(i) and (j).

15BSECTION II – REPAYMENT PLAN AGREEMENT 16BIf you are requesting a Fair Hearing regarding this decision, you are not required to complete and sign the repayment plan at this time. However, you must complete and sign the Fair Hearing request on the reverse side of this form and return it to the address indicated on the reverse.

17BYou are required to make full repayment by 18B 19B. If you are unable to repay the overpayment as

20Bshown below or you want to set up another agreement plan, or if you have any questions please call 21B

22Bat 23B 24B, right away. Otherwise, sign this agreement, make a copy of it for yourself, and return the

25Bagreement to the address at the bottom of this page. If you do not respond to this notice, your case will be closed. 26BYour repayment plan is shown below.

Revised Family Share – Recovery will be made from your child care benefits. To repay this debt, you must pay

$ 29B 30Bper week. This is in addition to your current family share of $ 31B 32Bper week.

33BYour total family share is now $ 34B 35Bper week. You must make this payment each week to your child care provider.

36BYour first payment is due on 37B 38B. We will pay your provider $ 39B 40Bper week.

You must make weekly payments of $ 42B 43Bto the Department of Social Services. You must send payment to

44Bthe address below. Your first payment is due on 45B 46B. We will pay your provider $ 47B 48Bper week.

49BI agree to repay by this method. I understand that failure to pay the amount stated on time will result in a discontinuation of my child care benefits and/or legal action may be taken in the court to recover this overpayment.

50B

51BSIGNATURE 52BDATE

53BReturn this repayment plan agreement to: 54BReturn Payment to:

CLIENT/FAIR HEARING COPY

OCFS-LDSS-7009 (1/2005) REVERSE

RIGHT TO A CONFERENCE: You may have an agency conference to review these actions. A conference is when you meet with someone from the agency, other than the person who made the decision, to discuss your case. You may request an agency conference by calling the number on the front of this notice, in the upper right hand corner. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. Requesting an agency conference is not the same as requesting a fair hearing. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you disagree with the decision made by our agency, you may request a fair hearing. At the hearing you will have the opportunity to present written and oral evidence to demonstrate why you think the agency’s decision is wrong and the action should not be taken. You have the right to be represented by legal counsel, a relative, friend or other person, or you may represent yourself. You have the right to bring witnesses and to question witnesses at the fair hearing. You have the right to present written and oral evidence at the hearing, and should bring any documents that may be helpful in presenting your case, such as this notice, pay stubs, receipts, child care bills, medical verification, letters, etc. There is additional information below on how to obtain access to your file and copies of documents in your file.

55BYOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING: When you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or, to represent yourself.

TO REQUEST A FAIR HEARING:

Telephoning: 1 800-342-3334 (Please have this notice with you when you call). Online: Complete an online request form at: HTUhttp://www.otda.state.ny.us/oah/forms.aspUTH. Walk In Locations: 14 Boerum Place, Brooklyn, NY OR 330 West 34P

thP Street, Third Floor, Manhattan, NY.

Writing: Complete the following information, sign and mail a copy of this entire notice to the New York State Office of Administrative Hearings, Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201. Please keep a copy for yourself. Faxing: Complete the following information, sign and fax this entire notice to the New York State Office of Administrative Hearings at: 518-473-6735.

I want a fair hearing. The Agency’s action is wrong because:

I understand I may be eligible for aid continuing (current recipients only). My benefits have been stopped and I wish to have my benefits restored (aid continuing) until the hearing decision is issued. If you request a fair hearing and aid continuing, within ten (10) days of the date of the postmark of the mailing of this notice, your child care will be reinstated and will be unchanged until the fair hearing decision is issued. However, if you lose the fair hearing, you will owe any child care that you should not have received. We are required to recover any child care overpayments. We must make a claim against you for any child care you receive that you were not entitled to, which may be collected by reduction of future child care benefits, through lump sum installment payments, or through legal action. If you want to avoid this possibility you can check the box below. You can also indicate over the telephone or in a letter that you do not want reinstatement of your child care.

I do not want my benefits continued until the hearing decision is issued.

Signature of Client: Date:

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice. ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: You have a right to look at your case file, and to receive free copies of the documents that the agency will put into evidence and other documents necessary for you to prepare for the fair hearing. To review your file or receive copies of any documents in your file, you can call us at the Record Access telephone number listed at the top of page 1 of this notice or write us at the address printed at the top of page 1 of this notice. If you want the documents mailed to you, you must specifically ask that they be mailed. You should ask for documents ahead of time. They will be provided to you within a reasonable time before the date of the hearing.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get copies of documents, call us at the telephone numbers listed at the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice.

OCFS-LDSS-7010 (1/2005) FRONT NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES NOTICE OF FRAUD DETERMINATION,

DISQUALIFICATION FOR CHILD CARE BENEFITS AND REPAYMENT PLAN

NOTICE DATE


CASE NUMBER:

CIN NUMBER:

CASE Name (And C/O Name if Present) and ADDRESS

GENERAL TELEPHONE NO. FOR QUESTIONS OR HELP

OR Agency Conference Fair Hearings Information and Assistance 1-800-342-3334Record Access

Legal Assistance Information OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

TELEPHONE NO.

YOU HAVE THE RIGHT TO AN AGENCY CONFERENCE AND TO A FAIR HEARING TO APPEAL THIS DECISION. BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO REQUEST AN AGENCY CONFERENCE AND/OR A FAIR HEARING. SECTION I – THIS NOTICE IS TO INFORM YOU: 1. The Department of Social Services has determined that you have fraudulently received child care benefits and you are

disqualified from receiving child care benefits, AND 2. You have received an overpayment and you must repay the overpayment.

The regulation which allows us to do this is: 18 NYCRR 415.4(i).

SECTION II – FRAUD DETERMINATION The Department’s finding of fraudulent receipt of child care benefits was based on:

Your conviction by a court of law on of fraudulently receiving child care benefits. Your signing a voluntarily admission dated .

The fraudulent activity resulted in an overpayment of $ , occurring from to .

SECTION III – LENGTH OF DISQUALIFICATION PERIOD As a result of the fraudulent receipt of benefits, you are disqualified from receiving child care benefits. New York State regulation, 18 NYCRR 415.4(i)(13), establishes time periods for suspension or termination of benefits depending on the number of offenses and theamount of fraudulent benefits received.

Six months, because this is your first offense.

12 months, because this is your second offense or the amount of fraudulent benefits you received was between $1,000 and $3,900.18 months because this is your third offense, or the amount of fraudulent benefits you received was in excess of $3,900.Five years, because you have committed four or more previous offenses.Other (State length of period and reason):

SECTION IV – EFFECTIVE DATE OF DISQUALIFICATION Your disqualification will begin on and end on .

You will be subject to the above disqualification penalty if you apply for and are found eligible for child care benefits at a future date.Your disqualification period will begin or resume once you are no longer participating in an activity required by TA.

SECTION V: REPAYMENT PLAN AGREEMENT If you are requesting a Fair Hearing regarding this decision, you are not required to complete and sign the repayment plan at this time. However, you must complete and sign the Fair Hearing request on the reverse side of this form and return it to the address indicated. You are required to make full repayment by . If you are unable to repay the overpayment as shown below or you want to set up another agreement plan, or if you have any questions, please call at , right away. Otherwise, sign this agreement, make a copy of it for yourself, and return the agreement to the address at the bottom of this page. Your repayment plan is shown below.

Recovery will be made from your child care benefits. To repay this debt, you must pay $ each week to your child care provider. This is in addition to your current family share of $ per week. Effective ,your total family share will be $ per week and the amount we pay to your provider will be reduced to $ .

To repay this debt, you must pay the Department of Social Services $ per week. Your first payment is due on . The final payment is due on .

Send payments to:

You must continue to follow the repayment plan and/or court order that is already in effect, and is attached to this notice.

I agree to repay by this method. I understand that failure to pay the amount stated above on time will result in a discontinuation of my child care benefits and/or legal action may be taken in the court to recover this overpayment.

SIGNATURE DATE

Return this repayment plan agreement to:

CLIENT/FAIR HEARING COPY

OCFS-LDSS-7010 (1/2005) REVERSE

RIGHT TO A CONFERENCE: You may have an agency conference to review these actions. A conference is when you meet with someone from the agency, other than the person who made the decision, to discuss your case. You may request an agency conference by calling the number on the front of this notice, in the upper right hand corner. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we determine to change our decision, we will take correctiveaction and give you a new notice. Requesting an agency conference is not the same as requesting a fair hearing. Read below forfair hearing information.

RIGHT TO A FAIR HEARING: If you disagree with the decision made by our agency, you may request a fair hearing. At the hearing you will have the opportunity to present written and oral evidence to demonstrate why you think the agency’s decision iswrong and the action should not be taken. You have the right to be represented by legal counsel, a relative, friend or other person, or you may represent yourself. You have the right to bring witnesses and to question witnesses at the fair hearing. You have the right to present written and oral evidence at the hearing, and should bring any documents that may be helpful in presenting yourcase, such as this notice, pay stubs, receipts, child care bills, medical verification, letters, etc. There is additional information below on how to obtain access to your file and copies of documents in your file.

YOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING: When you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or, to represent yourself.

TO REQUEST A FAIR HEARING:

Telephoning: 1 800-342-3334 (Please have this notice with you when you call). Online: Complete an online request form at: http://www.otda.state.ny.us/oah/forms.asp.Walk In Locations: 14 Boerum Place, Brooklyn, NY OR 330 West 34th Street, Third Floor, Manhattan, NY. Writing: Complete the following information, sign and mail a copy of this entire notice to the New York State Office of Administrative Hearings, Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201. Please keep a copy for yourself. Faxing: Complete the following information, sign and fax this entire notice to the New York State Office of Administrative Hearings at: 518-473-6735.

I want a fair hearing. The Agency’s action is wrong because:

I understand I may be eligible for aid continuing (current recipients only). My benefits have been stopped and I wish to have my benefits restored (aid continuing) until the hearing decision is issued. If you request a fair hearing and aid continuing, within ten (10) days of the date of the postmark of the mailing of this notice, your child care will be reinstated and will be unchanged until the fair hearing decision is issued. However, if you lose the fair hearing, you will owe any child care that you should not have received. We are required to recover any child care overpayments. We must make a claim against you for any child care you receive that you were not entitled to, which may be collected by reduction of future child care benefits, through lump sum installment payments, or through legal action. If you want to avoid this possibility you can check the box below. You can also indicate over the telephone or in a letter that you do not want reinstatement of your child care.

I do not want my benefits continued until the hearing decision is issued.

Signature of Client: Date:

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice. ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: You have a right to look at your case file, and to receive free copies of the documents that the agency will put into evidence and other documents necessary for you to prepare for the fair hearing. Toreview your file or receive copies of any documents in your file, you can call us at the Record Access telephone number listed at the top of page 1 of this notice or write us at the address printed at the top of page 1 of this notice. If you want the documents mailed to you, you must specifically ask that they be mailed. You should ask for documents ahead of time. They will be provided to you within a reasonable time before the date of the hearing.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get copies of documents, call us at the telephone numbers listed at the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice.