Supplemental NutritionAssistance Programin New York State

An Eligibility Prescreening GuideOctober 2015 edition

Supplemental NutritionAssistance Programin New York State

An Eligibility Prescreening GuideOctober 2015 edition

For questions or comments related to this guide, please contact the SNAP Technical Assistance Specialist at 518-436-8757 ext 126.

14 Computer Drive East • Albany, NY 12205 • 518-436-8757 • HungerSolutionsNY.org

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TABLE OF CONTENTS

INTRODUCTION………………………………………………………………………………………………………………… 4 THE APPLICATION PROCESS………………………………………………………………………………………………. 5 The Application Form…………………………………………………………………………………………………….. 5 NYS “myBenefits” Screening Tool and “myBenefits” Online SNAP Application……………. 6 Accessing the Application……………………………………………………………………………………………… 6 Filing the Application……………………………………………………………………………………………………. 7 Applying for SNAP When Not Applying for Cash Assistance Benefits…………………………... 8 Timeliness……………………………………………………………………………………………………………………… 8 SNAP Expedited Service………………………………………………………………………………………………. 10 THE SNAP INTERVIEW…………………………………………………………………………………………………….. 12 Phone Interviews……………………..…………………………………………………………………………………. 12 Authorized Representatives……………………………………………………………………………………..... 13 Notice of Missed Interview Rules at Application………………………………………………………… 13 VERIFICATION AND DOCUMENTATION………………………………………………………………………….. 15 Collateral Contacts……………………………………………………………………………………………………… 15 Computer Matches for Verification……………………………………………………………………………. 16 Necessary Verification………………………………………………………………………………………………… 16 Verification of Questionable Information………………………………………………………………….. 18 Front End Detection Systems……………………………………………………………………………………... 19

Social Security Numbers…………………………………………………………………………………………….. 19 Households With Undocumented Non-Citizens…………………………………………………………. 20 People Who Do Not Speak English……………………………………………………………………………… 20 Accommodating Persons With Disabilities………………………………………………………………... 20 Notification of Acceptance or Denial…………………………………………………………………………. 21 STATUS-BASED LIMITATIONS………………………………………………………………………………………… 22 Students…………………………………………………………………………………………………………………….. 22 Strikers………………………………………………………………………………………………………………………. 24 Non-Citizen Eligibility……………………………………………………………………………………………….. 24 Fleeing Felons and Probation Officers……………………………………………………………………….. 26 WORK REQUIREMENTS………………………………………………………………………………………………….. 27 Voluntary Quit……………………………………………………………………………………………………………. 28 Able-Bodied Adults Without Dependents (ABAWDs)………………………………………………… 28 Work Sanctions, Internal Program Violations……………………………………………………………. 29 HOUSEHOLD COMPOSITION…………………………………………………………………………………………. 30 Special Rules for Homeless Youth, Foster Care Children, and Boarders….………………… 30 Special Rules for Severely Disabled People Living With Others………………………………… 31 EXPANDED CATEGORICAL ELIGIBILITY………………………………………………………………………..... 32 Households with Dependent Care Costs…………………………………………………………………… 32 Households that ARE NOT Categorically Eligible………………………………………………………. 33 CALCULATING A BUDGET………………………………………………………………………………………………. 35 Overview of Budgeting……………………………………………………………………………………………… 35 Household Information……………………………………………………………………………………………… 36

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Using the SNAP Budget Worksheet……………………………………………………………………………. 36 BUDGET WORKSHEET……………………………………………………………………………………………………. 39 Income……………………………………………………………………………………………………………………….. 39 Deductions…………………………………………………………………………………………………………………. 40 Shelter Expenses………………………………………………………………………………………………………… 42 Excess Shelter Deduction……………………………………………………………………………………………. 44 Calculating the Excess Shelter Deduction…………………………………………………………………… 44 Calculating the SNAP Benefit Allotment…………………………………………………………………….. 44 ADVANCED BUDGETING…………………………………………………………………………………………………. 46 Income of Ineligible Household Members………………………………………………………………..... 46 Budgeting for Non-Citizens…………………………………………………………………………………………. 46 Budgeting Shelter Costs for Homeless People.……………………………………………………………. 47 Budgeting Rules for Other Groups………………………………………………………………………………. 48 Self-Employment Income……………………………………………………………………………………………. 48 Military Families………………………………………………………………………………………………………….. 50 KEEPING AND USING BENEFITS……………………………………………………………………………………….. 52 Using SNAP Benefits…………………………………………………………………………………………………… 52 Eligible Food Items………………………………………………………………………………………………………. 53 SNAP Monthly Benefits Issuance Schedule………………………………………………………………….. 54 Recertification and Reporting Requirements………………………………………………………………. 54 Telephone Recertification……………………………………………………………………………………………. 55 Changes Between Certification Periods………………………………………………………………………. 55 Case Reactivation Waiver……………………………………………………………………………………………. 56 Emergency Food Replacement……………………………………………………………………………………. 58 Disaster SNAP……………………………………………………………………………………………………………… 59 Transitional Benefits…………………………………………………………………………………………………… 59 New York State Nutrition Improvement Project – NYSNIP…………………………………………. 60

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LIST OF APPENDICES

APPENDIX A: COMMON ACRONYMS

APPENDIX B: ORGANIZATIONAL CHART OF SNAP

APPENDIX C: “HOW TO” SHEET FOR ORDERING SNAP APPLICATIONS & OTDA ORDER FORM 876 EL APPENDIX D: SNAP APPLICATION FORM (LDSS-4826) & “HOW TO COMPLETE” BOOKLET (LDSS-4826A)

APPENDIX E: SNAP APPLICATION EXPEDITED PROCESSING SUMMARY SHEET (LDSS-3938)

APPENDIX F: DOCUMENTATION REQUIREMENTS CHECKLIST (LDSS-2642)

APPENDIX G: TA/SNAP DOCUMENTATION/VERIFICATION DESK GUIDE (LDSS-3666)

APPENDIX H: NON-CITIZEN ELIGIBILITY CHART (LDSS-4579)

APPENDIX I: WORK RULES DESK GUIDE

APPENDIX J: CATEGORICAL ELIGIBILITY DESK GUIDE

APPENDIX K: BUDGET WORKSHEET

APPENDIX L: CHECKLIST FOR STUDENT ELIGIBILITY

APPENDIX M: HOUSEHOLD COMPESITION DESKGUIDE (LDSS 4314)

APPENDIX N: AUTHORIZED REPRESENTATIVE REQUEST FORM (LDSS 4942)

APPENDIX O: REQUEST FOR REPLACEMENT SNAP (LDSS 2291)

APPENDIX P: CHANGE REPORT FORM (LDSS 3151)

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INTRODUCTION

This Supplemental Nutrition Assistance Program (SNAP) prescreening guide is designed for human service agencies, advocates, and volunteers working with low-income households who wish to:

(1) Determine which households may qualify for SNAP benefits as well as theirestimated SNAP benefit allotment;

(2) Assist potentially eligible households through the SNAP application process; and

(3) Assist current SNAP participants in the recertification process.

This guide only briefly addresses SNAP work rules. The New York State Temporary Assistance and SNAP Employment Policy Manual provides a comprehensive explanation of SNAP’s employment and training requirements. It focuses on the application process and establishing eligibility. Hunger Solutions New York encourages advocates to try to resolve problems by communicating with local SNAP offices.

About the Supplemental Nutrition Assistance Program (SNAP) (12-ADM-07; Appendix B)

Governor Cuomo signed into law a bill to change the name of New York State's Food Stamp Program to the national name of "Supplemental Nutrition Assistance Program" (SNAP) in June of 2012. SNAP, the new name for the Food Stamp Program, is a state-administered federal nutrition assistance program. Federal law governs the criteria for eligibility and levels of benefits. Each state is responsible for determining and documenting eligibility, issuing benefits, and maintaining records.

The United States Department of Agriculture (USDA) administers the program at the national level. In New York State, the Office of Temporary and Disability Assistance (OTDA) oversees the local administration of SNAP. Most administrative functions are delegated to counties through local departments of social services (LDSS). In New York City, the Human Resources Administration (HRA) administers SNAP (Appendix B: Organizational Chart). Please note that throughout this guide, LDSS is also referred to as the “local office” and “SNAP office,” as applicants and offices use these terms interchangeably.

New York State policy is explained in detail in the Supplemental Nutrition Assistance Program Sourcebook (SNAPSB). The sourcebook includes New York State’s instructions to the local districts on the administration of SNAP. The sourcebook is essential to anyone working with SNAP in New York State.

Throughout this guide, various headings will refer back to the specific section of the SNAPSB. Recent policy changes issued through administrative directives (ADMs), informational letters (INFs), local commissioner memoranda (LCMs), and General Information Messages (GIS) can be found at OTDA’s website.

Please note that this guide is updated annually to reflect the October 1 SNAP standards/ deductions/adjustments, as well as policy changes that occurred throughout the year. This version of the guide is valid from October 1, 2015 through September 30, 2016, but does not take into account any policy changes that have been instituted after September 2015. Hunger Solutions New York provides SNAP Policy Updates (on our website) that highlight new policy changes or clarifications provided to SNAP offices throughout the year.

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THE APPLICATION PROCESS

(SNAPSB Section 3 & 4; 10-INF-22) The application process begins with getting an application, filling it out, and submitting (filing) the application to the local department of social services office (LDSS) or the Human Resources Administration (HRA) in New York City. The applicant must then:

• Be interviewed - this must be scheduled for a specific day and at a specific time or be done at the time the application is submitted.

• Provide information about the circumstances of those applying, and • Provide verification of the criteria necessary to determine eligibility.

The application process is paperwork intensive and can be complicated— but, getting SNAP benefits can make the difference between going hungry and having food on the table.

The Application Form (SNAPSB Section 3: p. 6, Section 4: p. 17; 03-ADM-03; 10-INF-22; 12-INF-12 Appendix C and D) Applicants apply for SNAP by filing an application form. Anyone can get an application form online or by contacting any SNAP office. If an individual goes to the SNAP office and asks for an application, the office must give them one. If a person asks a SNAP office to mail an application form, the office must mail it that same day. Many human service agencies keep a supply of SNAP applications on hand. New York State has two application forms:

• 6-page simplified SNAP application—a SNAP-only application (Appendix D) • 16-page common application form—also known as the joint application—used by

anyone who wishes to apply for multiple assistance programs Previously, all applications contained the OTDA “Helping Hands” brochure to confer ‘categorical eligibility’ for SNAP benefits (12-INF-12 and Appendix J). However, the brochure is no longer required to be included in application packets. The Helping Hands brochure information is incorporated as an addition to the client approval notices provided at application and recertification. Households applying for multiple assistance programs (Temporary Assistance (TANF), SNAP, Medicaid, and/or child care assistance) should utilize the joint application form. Anyone applying for TANF is also considered to be a SNAP applicant, even though eligibility guidelines and definitions of household composition vary. There are boxes on the form where the applicant can check off the programs for which they want to apply. If the applicant is found eligible for SNAP but not TANF, the SNAP application should be accepted and opened as a SNAP-only case. In most districts, the case will be transferred to an “NPA (non-public assistance)” SNAP unit or office.

Please see Appendix C for simple “How To” instructions for Community Agencies wanting to order SNAP applications and other brochures from OTDA. This appendix also includes the necessary order form.

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Anyone has a right to submit an application to any SNAP office in NYS and that office must forward the application to the correct SNAP office based on the applicant’s county of residence. However, this is not always a smooth process. Therefore, it is best to be clear about a county’s SNAP application procedures and direct applicants to the SNAP office in their county of residence. For a listing of all local county departments of social services in NYS, go to: http://otda.ny.gov/workingfamilies/dss.asp or call the toll-free hotline at 1-800-342-3009. NYS “myBenefits” Screening Tool and “myBenefits” Online SNAP Application “myBenefits” is an online tool available to all NYS residents to connect with benefits, services, and work supports. myBenefits is a single portal of NYS programs and benefits. It allows individuals and families to learn about and apply for an array of programs customized to fit their unique circumstances. Applicants follow basic instructions to answer a simple set of online questions. Applicant information will stay private and secure. To use myBenefits, go to: http://www.mybenefits.ny.gov. Currently, myBenefits covers the following benefit programs:

• Child and Dependent Care Tax Credit • Child Health Plus • Earned Income Tax Credit • EPIC • Family Health Plus • Healthy New York • HEAP • Medicaid • Noncustodial Parent Tax Credit

• Nutrition Education • Prescription Saver • School Meals • SNAP • Summer Meal Program • Temporary Assistance • Veteran Affairs • WIC • Programs continue to be added

Remember that Nutrition Outreach and Education Program (NOEP) Coordinators can provide an in-depth SNAP prescreening and also help potentially eligible families through the SNAP application process. For local NOEP contact information, please visit www.FoodHelpNY.org. Accessing the Application (10-INF-22) When distributing or accepting an application for SNAP, the SNAP/HRA office must follow federal and state regulations that require:

A. All people must be allowed to receive an application and/or apply for SNAP benefits at any time during the regular business hours of the local office.

B. SNAP offices must NOT establish any of the following:

o Periodic daily quotas on application submissions;

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o Limits on application pickup or submission times during normal office business hours;

o Limits on daily submissions based on the number of available interview slots; or

o Zip code or alphabetic restrictions that limit when a person may request or submit an application during a local district’s business hours.

C. A household’s right to apply and be interviewed for SNAP must not be denied

or limited due to: o National origin; o Citizenship status of any member of the household; or o For any other reason.

D. All people applying for SNAP, including those submitting applications by mail,

shall: o Have an interview scheduled on a specific day and at a specific time if

they are not interviewed on the same day they apply. o Receive expedited benefits no later than five days following the date of the

application. • This means that the LDSS/HRA office must schedule the interview

in a timeframe that is consistent with the five-day rule. Filing the Application (SNAPSB Section 4: pp. 3, 9, 19, 27; 13-INF-05) Applicants should turn in a completed application form right away. The form does not have to be completely filled out to be turned in, but it is best to provide as much information as possible when submitting a SNAP application. To be submitted and accepted as an “identifiable application” the application must include at minimum the applicant’s name, address, signatures, and the date. Applications can be turned in:

• by mail • in person • by a third party (friend, relative, or

community agency representative) • by fax, or • completed online

Some SNAP offices may have trouble with mailed/faxed applications, either because they do not understand that they must accept applications by mail/fax or simply due to logistical problems. Mediating on behalf of SNAP applicants with those SNAP offices that will not accept applications by mail/fax may result in better access for future SNAP applicants in that county. HRA in NYC has a Mail-In Application and Referral Unit (MARU). MARU allows households citywide to request a SNAP application package by mail by calling the city’s 311 information line. MARU applications can then be returned by mail to the HRA MARU

The date the application is turned in is called the filing date. The filing date is very important because, if approved, SNAP benefits are issued based on the filing date, not the date the application is approved.

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Center by using MARU Business Reply Envelopes (form #W90A). Community-based organizations assisting households with SNAP applications can also use MARU Business Reply Envelopes (form #W90A). NYC HRA implemented a fax system for their new Mail-In Application and Referral Unit (MARU). Applicants do not have to wait for a caseworker to see them before they turn in their applications at their county SNAP Office. They can drop off (file) the application and come back for the interview at a later date. Applicants will have to provide more information during the interview (see page 12 for more information on interviews). All SNAP offices must post the LDSS-4995 “Right to File” poster in their reception areas. This poster provides information concerning the rights of individuals to file a SNAP application.

Applying for SNAP When Not Applying for Cash Assistance Benefits (SNAPSB Section 4: pg. 3, 12) If a SNAP applicant submits a joint application for TA and SNAP and is determined not eligible for TANF, the LDSS must continue to process their SNAP eligibility based on the original joint application. The applicant cannot be made to submit a new application. This should not cause any delay in processing the SNAP application. Timeliness (14-INF-16; SNAPSB Section 3: pg. 4; Section 4: pp. 9, 20-23) Once the SNAP office receives an application, it has no more than 30 days to act on the application and issue SNAP benefits if the household is eligible. The SNAP office must make a timely decision on the SNAP application. Delays are usually the result of problems with obtaining documentation, although they are sometimes caused by administrative or workload problems within the SNAP office. SNAP offices must give applicants at least 10 days to submit all the necessary documentation. If the applicant is having difficulty securing the required documents, the SNAP office must assist them in obtaining the verification. If the SNAP office does not make a decision on an application within the normal 30 days, we recommend contacting a SNAP supervisor or manager to discuss the situation.

Note: If everyone in a household is applying for or receiving Supplemental Security Income (SSI) benefits, which are administered by the Social Security Administration (SSA), the household can file their SNAP application at SSA. An SSA representative will forward the SNAP application to the proper SNAP office for processing. Single SSI live-alone recipients are now automatically enrolled in SNAP through a special project called the New York State Nutrition Improvement Project (NYSNIP); see page 60 for more information.

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Delays Caused By the Applicant(s) If the applicant does not turn in the required documents within the time period allotted by the SNAP office, and does not have good reason, the SNAP application can be denied. Applicants who submit any missing documents within the initial 30-day application period, and who are otherwise found eligible for SNAP, must have their case opened and be provided SNAP benefits back to the application date. No new application is required. Similarly, if the applicant submits the missing documents after the initial 30-day period, but within 60 days of the application date, the SNAP office must open the case, but benefits will not be provided back to the date of application; instead the case will be opened as of the month following the application month (the second 30-day period). Applicants wishing to submit any missing documents later than 60 days after their initial application date must file a new SNAP application. Delays Caused By the SNAP Office If the applicant has submitted all of their documents and is eligible for SNAP, but the SNAP office hasn’t provided the applicant with SNAP benefits within the allotted 30 days, then the SNAP office must provide SNAP benefits back to the day the application was first handed in. This is true even if the LDSS does not decide on the application until more than 60 days after it was submitted. When a household submits a SNAP application that has not been processed within the 30 day time period and the delay is caused by the SNAP office, the household will receive a notice that the SNAP application is “pending”. This is an effort to keep the applicant informed; however the application will be completed as timely as possible and SNAP

TIMELINESS: PROMPT ACTION TIME FRAMES

ACTION TIME FRAME

Providing application forms to households Same day the request is received

Accepting an identifiable application Same day as received

Expedited service screening Same day that an application is received

Application interview As soon as possible after receipt of an application

(Households eligible for expedited service should be interviewed within 5 days of their application date.)

Application processing/eligibility determination and issuance of benefits

As soon as possible and always within 30 days of application

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benefits will be provided back to the day the application was submitted. SNAP application processing time is mandated by federal regulations and should be adhered to by SNAP offices. SNAP Expedited Service (05-ADM-13; 12-INF-06; SNAPSB Section 4: pg. 24-25; Section 5: pp. 128, 133-136; Section 15: pp. 316-317; Section 20: pg. 381; Appendix E) People with very low income and few resources may qualify for “expedited service” under the federal rules and regulations for the program. Everyone who applies for SNAP must be screened for eligibility for expedited service on the day they apply. New York has a standard screening form for this (LDSS-3938). Some SNAP offices may not always screen for expedited service when they should. Therefore, SNAP applicants should always ask to be screened for expedited service. People eligible for expedited service will get their SNAP benefits within 5 calendar days of the filing date. Many districts, including HRA, have a practice of making benefits available on the day of application. Expedited SNAP benefits is not a separate program, but instead a right to get SNAP more quickly. For those meeting the expedited criteria, this service is provided while the ongoing SNAP application is being processed. An applicant is still eligible to apply for and receive expedited service, even if they have an authorized representative, such as a friend or relative, apply for them. They may also have a phone interview or an interview in their home if they are unable to get to the LDSS office.

ELIGIBILITY FOR EXPEDITED SNAP BENEFITS

A household is eligible for expedited service if: 1. Their liquid resources (cash or readily available savings) do not exceed $100 and they

have received less than $150 in gross income during the calendar month in which they are applying for SNAP; OR

2. The household’s shelter costs for the month – rent or mortgage, plus utility expenses (the Standard Utility Allowance) – are greater than the combination of the household’s liquid resources and gross income for the calendar month in which they are applying; OR

3. They are a migrant or seasonal farm worker household who have liquid resources of $100 or less and meet SNAP requirements for being destitute.

After determining that a household meets any one of the above three conditions, the SNAP office must interview the household and obtain proof of the applicant’s identity so that expedited benefits can be issued. No other verification is required for expedited SNAP purposes. Identity can be verified through either:

• a driver's license • a voter registration card OR

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• any other document that proves the applicant’s identity.

If the applicant does not have any ID, the SNAP office must try to call someone (such as a friend, a relative, or a worker at a shelter or other agency) to verify their identity. The SNAP office should attempt to obtain as much verification as possible during the interview. Expedited processing should not be delayed due to a lack of verification (other than identity) if it is likely that the other verification cannot be obtained within the 5 day time frame. The SNAP office should use the information submitted on the application for expedited budgeting purposes even if this information has not been verified. If no verification of identity is possible, then benefits cannot be issued. If the applicant qualifies for expedited service, they must get their SNAP benefits within 5 calendar days. For example, if a person applies on a Monday and qualifies for expedited service, the SNAP office must provide SNAP benefits by the following Saturday. Even if the office is closed on Saturday, it must get the EBT (Electronic Benefit Transfer) card to the family and have the benefits authorized by Saturday. The SNAP office must also assess whether the applicant has ever received expedited SNAP benefits in the past. Families who received expedited SNAP benefits the last time they applied but were not certified for ongoing benefits (because they didn’t follow through with the verification process) have to meet certain additional criteria the next time they apply in order to receive expedited SNAP benefits. In order to be processed for expedited benefits, these applicants must submit either:

• the missing verification from their last application OR • all verification required with their new application*

Once the applicant has submitted all the necessary documents and is found eligible, the SNAP office must provide SNAP benefits within the expedited time frame (5 days). The SNAP office must give the household at least 10 days to gather paperwork for ongoing benefits.

∗Technically, these households are not eligible for expedited SNAP benefits under federal rules. However, if they submit all their current verification, New York State’s policy as outlined in 05 ADM-13 directs local districts to issue ongoing SNAP benefits using the expedited time frame of 5 days, rather than making the household wait up to 30 days.

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THE SNAP INTERVIEW (GIS 06 TA/DC 010; GIS 08 TA/DC018; SNAPSB Section 4: pp. 5, 11;

Appendix N) All SNAP applicants must be interviewed either in person or over the phone. Applicants can be interviewed at the time of application submission or at a later date. Applicants are always able to have an in-person interview when requested and they can bring anyone they want with them, including legal representation. Applicants are scheduled for an interview as quickly as possible. Applicants eligible for expedited processing must be interviewed within 5 days of submitting the application. The SNAP worker will cover the following in the interview:

• review application, • clarify any incomplete or confusing information, • ask additional questions as needed, and • provide a list of any missing documentation and give the applicant at least 10 days

to turn in the needed information.

Phone Interviews (07-ADM-10; 08-INF-07; LDSS 4921) Many SNAP applicants will automatically be granted a phone interview, as opposed to having an in-office interview. The phone interviews are helpful to applicants because they do not need to go to the SNAP office in person. This is especially helpful for working families and people with disabilities. Phone interviews are granted for:

Working Families: Any non-temporary assistance SNAP applicants get an automatic phone interview when one of the following conditions is met:

1. One adult on the application is working 30 hours or more per week or earning an average of at least the federal minimum wage ($7.25/hour) multiplied by 30 hours per week. Ultimately, the adult on the application would need to average $217.50 gross per week.

2. Two adults on the application are each working 20 hours per week or earning at least the federal minimum wage ($7.25/hour) multiplied by 20 hours per week. In this instance each adult would need to be earning $145 gross per week, for a total of $290 per week.

Application Submission Type: Submitting an electronic application (ex. myBenefits or AccessNYC) results in an automatic phone interview. In addition, in NYC only, when applicants apply using the Mail-In Application and Referral Unit system (MARU), they are automatically scheduled a phone interview. This process allows NYC residents to apply by mail or fax at some community agencies, or by using the 311 system.

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Others By Request: Many other applicants can request a phone interview on a case-by-case basis. Applicants demonstrating a hardship are welcome to request a phone interview. Hardships can include transportation difficulties, illness, prolonged severe weather, care of a household member, or work hours that conflict with the SNAP office hours. Disabled/Senior Applicants: When an application is submitted by a household comprised of all elderly and/or disabled adults with no earned income, then special rules can apply. If these types of applicants request to forego the in-office interview, they can be granted a telephone interview or the SNAP office can send a worker to the home for the interview. All home visits are required to be scheduled in advance; the worker cannot show up without notice. Authorized Representatives (Appendix N) SNAP applicants can appoint an “authorized representative” who can apply on their behalf, including attending the interview and using the EBT card to make purchases if approved.

• The authorized representative can be a friend, a relative, someone who works for an agency, or anyone else the applicant chooses.

• This person cannot be part of the applicant’s household, but must be able to provide the SNAP office all the information it needs to determine eligibility, including the household’s documentation.

• If an applicant wants someone to act as an authorized representative, an adult member of the household must provide a written notice to the SNAP office giving the person permission to act as their authorized representative. It is recommended to use the OTDA form (LDSS 4942).

• The SNAP office cannot force an applicant to use an authorized representative. OTDA form LDSS-4942:

• Is specifically for households wishing to designate an authorized representative • Is available in both English and Spanish • Cannot be required by the LDSS, but it is recommended • Is developed for use with the new electronic application, but is available statewide

for use with any applicant household

A copy of the form is provided in Appendix N. Notice of Missed Interview Rules at Application (GIS 08TA/DC018) SNAP offices must comply with the federal regulations for sending a Notice of Missed Interview (NOMI) during the SNAP application and recertification process.

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NYS policy reminds SNAP offices that they must follow these regulations during the application process:

1. If the SNAP office cannot interview the household on the day it is submitting the application, then the SNAP office must provide a date and time for the interview.

2. For new applicants that have missed their interview, the SNAP office must mail a “Notice of Missed Interview” letter (NOMI). This required notice informs the household that it is now the household’s responsibility to reschedule the eligibility interview.

3. If the new SNAP applicant fails to appear for the scheduled interview AND does not contact the local district upon receiving the NOMI, the district will deny the case for failure to comply with the eligibility interview requirement. The SNAP office must allow 30 days from the filing date before sending this denial notice. (The SNAP office will send the household two notices: 1. the NOMI and 2. denial letter.)

4. The SNAP office must reschedule the eligibility interview for all applicants that respond to the missed interview notice.

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VERIFICATION AND DOCUMENTATION (SNAPSB Section 5: pp. 114-127; 12-INF-06; Appendix F and Appendix G)

All eligibility criteria must be verified before the worker can determine that the household is eligible to receive a SNAP benefit. The SNAP office gains verification from documents, usually provided by the applicant(s), “collateral contacts” (people outside the applying household that the worker contacts), home visits, and computer matches. Every piece of information that is used to determine eligibility and a budget must be verified. Even if the worker is sure the information is true, s/he still must have some kind of verification for the file. If the applicant has receipts for their rent or mortgage payments, telephone and utility bills, and child care expenses, as well as pay stubs and verification of identity and address, they should bring these documents to the interview. For SNAP program purposes, any reasonable form of documentation must be accepted and the acceptable verification shall not be limited to any single type of document. The documentation requirements checklist (LDSS-2642 – see Appendix F) includes each eligibility criterion and acceptable forms of verification. One document may serve as verification for more than one eligibility criterion. If an applicant has tried to get a form of documentation and is unable to, then the caseworker is obligated to assist, including paying necessary fees. If the needed documentation is simply unavailable, the worker must find some other way to verify the eligibility criteria. Collateral contacts are almost always possible; even identity can be verified this way. Collateral Contacts (SNAPSB Section 5: pp. 121-122; 12-INF-06) When documentation is unavailable, the SNAP office will use a collateral contact. Collateral contacts are a substitute for written verification. The SNAP office calls the collateral contact directly for information to support what the household has reported. The worker is responsible for obtaining the information from the acceptable collateral contacts that have been provided by the applicant. The SNAP office can get information in writing, over the telephone, or in person. If the SNAP office wants to call someone, it should ask the applicant whom it could contact. If the applicant does not give the SNAP office an acceptable contact person, the SNAP office will identify a person to contact.

Case example: A birth certificate can serve as verification of identity, date of birth, and citizenship. OTDA has issued a desk guide (Appendix G: LDSS-3666) highlighting different forms of acceptable Primary and Secondary verification; however, SNAP does not differentiate between Primary and Secondary verification.

A collateral contact is a verbal confirmation of a household’s circumstances by a person outside the applicant’s household. For example, the SNAP office might call the landlord or neighbors to confirm the applicant’s address and household.

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When the SNAP office makes collateral contact it is inadvertently letting that person know that the applicant household is applying for some type of benefit. In order to approach a collateral contact, the SNAP office must get the applicant’s permission to disclose household information. If the family does not want a person selected by the SNAP office contacted, they should be given the chance to verify information in some other way, or to withdraw their application. The SNAP office should only call collateral contacts when other verification is unavailable or inadequate. The SNAP office should conduct a home visit only if it cannot verify household eligibility criteria through documentation or collateral contacts. Home visits are to be used on a case-by-case basis where the supplied documentation is insufficient. Applicants do not have to let workers visit their homes, but the LDSS can deny the application if it cannot verify the household’s eligibility. Computer Matches for Verification (12-INF-06)

• The SNAP office can get information from computer systems of other public benefit programs, the Internal Revenue Service (IRS), the Social Security Administration (SSA), some banks, the NYS Department of Motor Vehicles, tax collectors, or other agencies and organizations.

• The SNAP office may want information from these agencies’ computers because they have records about people’s wages, their benefit checks, their addresses, and sometimes other things that affect whether they qualify for SNAP.

• The SNAP office usually will not tell the applicant when it is checking information in this way. If the SNAP office gets information from computer records that affects the SNAP case, it will usually either contact the household to verify the information or refer the case to an internal investigation unit.

Necessary Verification (SNAPSB Section 5:pp. 114-117; 12-INF-06, GIS 13 TA/DC043) SNAP rules require that the SNAP worker get proof of the following:

1. Identity of applicant. If an authorized representative applies for an applicant, the SNAP office must verify both the identity of the authorized representative and the head of the household. Identity is the only necessary verification for households eligible for expedited processing.

2. Household size. Verification can be obtained from a collateral contact such as a landlord statement or other readily available documentation. For example: driver’s license, work ID, school district report, housing authority section 8, ID for health benefits or other assistance programs, wage stubs, or any other documents which can be used to establish identity.

3. Age. The household must provide the date of birth for all applying household members. The household has until the next recertification to provide verification of the date of birth. Examples of verification of date of birth include birth certificates, marriage certificates, and school records or the SSN validation.

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4. Citizenship status (also referred to as Alien Status by OTDA) of anyone in the household who is applying for SNAP and who is not a U.S. citizen. The SNAP office will verify the claimed legal status and any immigration documents submitted with the U.S. Citizenship and Immigration Services (USCIS, formerly known as INS or the Immigration and Naturalization Service). The SNAP office will only verify USCIS status for those household members who submit proof of their immigration status. Any non-citizen household members who do not submit proof of their immigration status (such as undocumented non-citizens) will be excluded from the household for SNAP purposes, but the rest of the household can still receive SNAP benefits.

5. Social security numbers (SSNs) of everyone in the household. In New York State, eligibility workers verify SSNs directly with the Social Security Administration (SSA). Therefore, individuals do not have to provide proof of their SSN unless the number they provide to the SNAP office does not match the SSA’s records or cannot be verified. Household members who do not already have a SSN (or do not know their SSN) must apply for a number before they can start receiving SNAP benefits, unless they have good cause for not applying. Failure or refusal to apply will mean that person is excluded from the household for SNAP purposes. That person will be treated as an ineligible non-citizen for budgeting purposes.

6. Income and resources.

7. Residence in the county. Residence is verified at a household level. The SNAP office does not have to verify where the applicant lives if it is not reasonably possible to get verification. For example: if the applicant recently moved to the area, is homeless, or is a migrant farm worker and cannot get verification easily. Homeless SNAP applicants do not need a permanent address to apply. They are specifically exempt from the residency verification. Homeless applicants can use the address of an authorized representative, a community organization (ex: shelter, soup kitchen), or the local SNAP office as an acceptable mailing address. See GIS 13TA/DC043 for more information on documentation requirements for homeless youth.

Note: If verification of an item used only for budgeting a deduction (#’s 7-10 above) is not available, the case can still be opened and budgeted without the deduction; however, the household may get a smaller benefit than it would have if the item had been verified.

The following documents are used for budgeting ONLY:

8. Shelter and utility costs. 9. Childcare and child support costs being deducted in the budgeting process. 10. Medical expenses for elderly and disabled applicants. 11. Disability if the applicant wants to use the special budgeting rules applicable

to disabled people or needs to be exempted from work activities.

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Case Example: If the household does not have verification of child care costs, the budget can be calculated without the child care deduction. When the household provides documentation for the child care expense, they might get an increase based on the new budget with the deduction.

When the verification is provided, the worker will re-budget and may increase the amount of SNAP benefits the household receives. The four items outlined in the above boxed list of necessary verification are used for budgeting purposes only, not eligibility determinations. The SNAP office cannot limit which forms of necessary verification it will accept, and must accept anything listed on the documentation checklist. Also, any other form of credible documentation should be accepted. As a practical matter, it is easiest to get an application accepted promptly if the usual forms of documentation are provided. The SNAP office should only ask a household to verify their present circumstances. They should only use verification to assess if the household is currently eligible.

Verification of Questionable Information (SNAPSB Section 5: pp. 119-120; 12-INF-06) The SNAP office will also ask for verification of any information that it finds questionable. These requests, and the guidelines upon which they are based, must not discriminate based on race, religion, ethnic background, or national origin. The applicant(s) should be ready to verify as many facts as possible. If there is anything unusual about the household’s circumstances, the applicant should try to explain it completely in the initial interview, rather than hope the worker will not notice. When SNAP workers ask for more information, they should give the applicant a written notice listing what information they need, along with the date by which the household should provide the information. The following items shall only be verified if questionable:

• Citizenship; • Household composition, and; • Whether members of the household purchase and prepare meals together or

separately.

Important Note About Verification: If an applicant cannot provide verification of an eligibility criterion, the SNAP office has an obligation to assist. This includes paying fees when necessary. SNAP offices can sometimes obtain copies of official documents, like birth certificates, without paying a fee. However, if a fee is required, the SNAP office must either pay it or find another way to verify the eligibility criterion.

To be considered questionable, the information on the application must be inconsistent with statements made by the applicant, inconsistent with other information on the application or previous applications, or inconsistent with information received by the worker.

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Front End Detection Systems (05-ADM-08) The Front End Detection System (FEDS) program is an anti-fraud measure allowed by New York State. FEDS conducts investigations of applications that appear to have questionable circumstances. For cash assistance purposes, all counties are required to operate a FEDS program. However, it is optional for SNAP-only cases. New York City does not have a SNAP-only FEDS plan; about two-thirds of counties throughout the state do. All local FEDS plans must be approved by OTDA. Caseworkers may only refer those cases which meet specific criteria spelled out in the county’s FEDS plan, and only after the household has first been given an opportunity to explain their situation. Typically, a FEDS referral results in an LDSS/HRA investigator visiting the applicant at their home, or asking the household to appear for an in-office interview. However, for SNAP purposes there is no obligation on the part of the household to meet with the investigator. A SNAP application cannot be denied due to a household’s failure to attend a FEDS interview. In this situation, the investigator should continue without the household’s cooperation and forward his/her report to the eligibility worker. The worker will then consider the information in the FEDS report before making a final decision on the household’s application. FEDS should not delay the normal application process. Social Security Numbers (SNAPSB Section 5: pp. 95-97) Every person in a household applying for SNAP must provide the SNAP office with his or her social security number (SSN). If a household member does not have a SSN, they must apply for one before they can receive SNAP benefits unless they have "good cause.” If an applicant applies for a SSN, the receipt from the SSA showing that they have applied for the SSN satisfies the requirement. Applicants who do not give the SNAP office their SSN or provide proof that they have applied for one, or who do not have good cause for not applying for a SSN, cannot receive SNAP benefits. However, the rest of the household members can proceed with the application without that household member. The excluded household member will be treated as an ineligible non-citizen for budgeting purposes. As soon as the household member qualifies (i.e. provides proof they have applied for a SSN), they will be added as a member of that SNAP case.

05-ADM-08 lists the type of criteria—called “indicators”—that can trigger a FEDS referral.

“Good cause” means that they have tried to apply for a social security number but cannot get it yet. For example, they may have good cause if the social security office will not take the application because they are waiting for a replacement copy of a lost birth certificate.

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Households With Undocumented Non-Citizens (03-INF-14; SNAPSB Section 5: pp. 69 - 89) Non-citizens who cannot verify their immigration status (often referred to as “undocumented”) are not eligible for SNAP benefits. When a household contains a member who cannot provide immigration verification, the SNAP office must continue to process the application for the remaining household members. The SNAP office is not to report anyone to United States Citizenship and Immigration Services (USCIS). The SNAP office can report a non-citizen to OTDA if presented with proof that the person is illegally in the country (deportation orders). A threat by the SNAP office to contact USCIS to verify immigration status is a violation of the non-citizen’s civil rights. If the ineligible non-citizen is someone who would otherwise have to be part of the SNAP household (for example, the parent of minor children in the household), his/her income must be reported because a pro-rata portion will count in determining the amount of SNAP benefits for which the rest of the family is eligible. More information on budgeting for this type of household can be found in the Advanced Budgeting section of this guide. People Who Do Not Speak English (06-ADM-05) People who do not speak English or have limited English proficiency (LEP) often have an especially difficult time navigating the SNAP application process. They cannot, and should not, be denied access to SNAP because of LEP issues. In New York State, the SNAP application form is available in English, Spanish, Arabic, Chinese, Haitian Creole, Korean, and Russian. SNAP offices should have applications on hand in all seven languages. SNAP offices must have an “Interpreter Services” poster in their waiting areas. This poster has information in many different languages about the availability of translation services to any individuals who need them. Additionally, SNAP offices must provide a translator or interpreter to any applicant who needs one. If the SNAP office does not have an interpreter or bilingual worker on staff, they should make other arrangements to provide translation services. Households can bring their own interpreter, but only if they wish to do so. New York City has special requirements to ensure that LEP households have access to translation services, as part of a class action lawsuit settlement, Ramirez v. Giuliani. Accommodating Persons With Disabilities (06-ADM-05; GIS 15 TA/DC023) SNAP is subject to the Americans with Disabilities Act (ADA) of 1990 and the Rehabilitation Act (RA) of 1973, which protect people who have a physical or mental disability. The ADA and the RA are not limited to people who are "disabled" under SNAP regulations. Therefore, the SNAP office must provide the accommodations required by these laws, even if the applicant is not considered disabled for SNAP purposes. OTDA

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issued a comprehensive policy directive (06-ADM-05) clarifying local districts’ obligations to provide equal access to persons with disabilities. In an effort to remain compliant with ADA standards, SNAP offices will be required to offer SNAP notices and materials in alternate formats including large print, braille, audio recordings, and data CDs upon request. This policy will be effective throughout all of New York State by June, 2016. Notification of Acceptance or Denial (SNAPSB Section 8; 14-INF-16) Whether a SNAP application is accepted or denied, the SNAP office must send a notice telling the applicant its decision within 30 calendar days of the application filing date.

If the SNAP office decides that applicant qualifies for SNAP, the notice of acceptance must: ● State how much the household’s SNAP benefit will be, and

● Include the start and end dates of the certification period.

If the SNAP office denies the application, this notice of denial must explain the reason for the denial. All notices must include the following information:

• Phone number of the SNAP office • The name of someone at the SNAP office the applicant can call with questions, if

possible • Information about the right to a fair hearing • How to get free legal aid

New York State uses an automated computer notice system for most notices. These computer-generated notices are very long and include a lot of information. The notices provide a lot of information about how the budget was calculated, so if there are any mistakes, these can be identified and mediated on with the SNAP office. The regular SNAP application processing time is 30 days from receipt of application, however there are times when an application cannot be processed within that time frame. When the application is delayed beyond 30 days and the fault lies with the SNAP office, the SNAP office has the responsibility of notifying applicants about the delay. A notice will be sent to applicants whose applications have not been processed within 30 days due to the fault of the SNAP office. A “Notice of Pending Application” will be created and sent to inform applicants that there has been a delay in application processing and that the application is still pending. Applications cannot be denied when the pending application is beyond 30 days and it is due to the fault of the SNAP office.

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STATUS-BASED LIMITATIONS Special rules limit the eligibility of certain groups of people. The main groups are: students, people on strike, non-citizens, and employable adults (work rules are covered in the next section). When dealing with a household that contains a person with a status-based limitation, it is important to evaluate each individual's eligibility, since some people in a household might be eligible, even if others are not. For example, a citizen child would still be eligible even if his/her non-citizen parent were not eligible. Special budgeting rules also apply in these cases. Students (SNAPSB Section 5: pp. 91-92; 09-ADM-08; 11-INF-06; 12-INF-14; Appendix L) STUDENT: A student is any person who is:

• 18 through 49 years of age • Physically and mentally fit • Enrolled at least half time in an institution of higher education

Definition of INSTITUTION OF HIGHER EDUCATION - Any institution at the post-high school level which normally requires a high school diploma or equivalency certificate for enrollment, including, but not limited to:

• Colleges • Universities • Business schools • Vocational schools • Trade or technical schools • Correspondence schools • On-line courses, and • Colleges or universities that offer degree programs regardless of whether a high

school diploma is required Students enrolled at least half time in higher education cannot get SNAP unless they meet at least one of the following exceptions:

• Employed an average of 20 hours a week or more • If self-employed, be working an average of 20 hours a week and make an average

income equal to the federal minimum wage multiplied by 20 hours • Participating in work study, even if it is less than 20 hours a week • 17 years old or younger • 50 years old or older • Physically or mentally unable to work (see work rules) • TANF recipient (complying with the TANF work rules) • A single parent enrolled full time who is responsible for the care of child under the

age of 12 • Primary caretaker of a household member who is under age 6 or is incapacitated • Primary caretaker of a household member between the ages of 6 and 11, if no

adequate childcare is available that would make it possible to work and go to school

Students receiving 50% or more of their meals from a college meal plan cannot get SNAP, as they are considered to be living in an institution.

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• Required to attend school by the SNAP employment and training program, or a similar program operated by a state or local government (This includes students receiving UIB.)

Students who do not meet one of these exceptions are excluded from the SNAP household and neither the income nor the resources of the ineligible student will be used in determining eligibility for the rest of the household. However, if the student makes any cash contributions to the remaining members of the household, this will count as income. The rest of the household members may still be eligible. For help in determining if a student meets any of these exceptions, see the Student Eligibility Checklist provided in this guide under Appendix L. Continuing Eligibility of Students Eligible students remain eligible between school breaks (vacations, summer, etc.) unless the student graduates, is suspended or expelled, drops out, or does not intend to register for the next school term (excluding summer semesters). Ineligible students remain ineligible between school breaks (vacations, summer, etc.), unless the student graduates, is suspended or expelled, drops out, or does not intend to register for the next school term (excluding summer semesters). Students who have work study lose their SNAP eligibility between semesters (if the break is a full month or longer) and in summer months unless the work study continues or they fit into another exemption. Example: If a student who participated in work study during the school year got a regular job during the semester breaks/summer months working an average of 20 hours a week, they would remain eligible for SNAP. Students Receiving Unemployment Insurance Benefits (UIB) (12-INF-14) A student who is receiving UIB and who is enrolled at least half time in an institution of higher education is considered to be an eligible student for SNAP purposes if they meet the following:

• Participate in one of the following UIB Educational Programs: o “599” Education Training Programs o Workforce Investment Act (WIA) o Trade Act Programs

• Enrolled in school through one of the following programs: o SNAP Employment and Training Program o Safety Net Assistance employment program activity

These students fall under the current student exemption that states, “Required to attend school by the SNAP Employment and Training Program, or a similar program operated by a state or local government.”

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Students enrolled in the above programs do not need to meet any additional student work requirements or fit into any additional student exemptions in order to participate in SNAP. Strikers (SNAPSB Section 5: pg. 131) If the primary wage earner of a household is participating in a job action (on strike, a walk-out, etc.), the striker and the whole household are ineligible for SNAP unless they were eligible for benefits before the strike began. Thus, the striker’s income before the strike will be budgeted and applied to the entire household as if s/he were still working. In this case, other household members cannot simply exclude the striker to establish a separate case. A household cannot get more SNAP benefits because its income goes down during the strike. If the striker leaves the household, the remaining household members become eligible again. The following people are NOT considered to be strikers:

• People who have been locked out • People out of work because of someone else’s strike • People in a different bargaining unit who are afraid to cross a picket line • People exempt from work registration (other than those exempt because they are

working) • Strikers who have been permanently replaced

Non-Citizen Eligibility (GIS 10 TA/DC005; 03-INF-14; Appendix H) Among the most complicated rules in SNAP are those applied to non-citizens. Although this is commonly referred to as immigrant eligibility, it is important to remember that it applies only to non-citizens who are legally present in the country. Naturalized citizens (immigrants who become citizens) receive the same benefits as all other citizens. Undocumented non-citizens – those who cannot prove that they are legally present in this country – are never eligible for SNAP. The desk guide prepared by OTDA (see Appendix H) is very helpful – it lists the categories of non-citizens who are eligible for SNAP (as well as cash assistance and Medicaid) along with what documents can be used to verify status.

CITIZEN: A person (other than a child of a foreign diplomat) who is born in: • One of the 50 states • District of Columbia • Puerto Rico • Guam • U.S. Virgin Islands • Northern Mariana Islands who

has not renounced or otherwise lost his or her citizenship

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The guiding principle is that in order for a non-citizen to be able to receive SNAP, the non-citizen must:

1. Have “qualified non-citizen” status AND 2. Meet a condition that allows qualified non-citizens to get SNAP.

Qualified Alien Status: Remember all non-citizens must meet one criterion from each list. Which non-citizens have qualified alien status?

• Lawful permanent residents (LPRs or “green card” holders)

• Refugees • Asylees • Persons whose deportation or

removal has been withheld • Persons paroled for at least 1 year • Cuban Haitian entrants • Amerasian immigrants

• North American Indians born in Canada

• Certain Hmong or Highland Laotian non-citizens

• Conditional entrants • Certain domestic violence

survivors

Which qualified non-citizens can get SNAP?

• Children under 18 with qualified alien status

• Disabled individuals with qualified alien status

• Adults who have held qualified alien status for at least 5 years

• Refugees (now includes Afghan and Iraqi Special Immigrants)

• Asylees • Persons whose deportation or removal

has been withheld • Cuban Haitian entrants • Amerasian immigrants • LPRs with substantial work history in the

U.S. (“40 quarters” test) • LPRs on active military duty or with

honorable discharge status, as well as their spouses and children under 18

Qualified non-citizens who came to the U.S. for humanitarian reasons – including refugees, asylees, and those with withholding of deportation – continue to be eligible for SNAP benefits even if they adjust their status to LPR. See Appendix H for further clarification on non-citizen status.

40 Quarters Test LPRs that can be credited with 40 qualifying quarters of work history are qualified to receive SNAP. One quarter is the equivalent of a 3-month period; therefore roughly 10 years of work equals 40 quarters. To count as a qualifying quarter, a worker must have earned a minimum salary during that quarter. Quarters of work history can be shared with some family members. Quarters earned during a marriage can be shared between spouses, even if separated or deceased (but not if divorced), and between parents and their children (for quarters worked before the child’s 18th birthday, including quarters worked before the child was born). The SNAP office will get the Social Security records of any worker’s quarters claimed by an applicant.

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Ineligible Non-Citizens Households containing ineligible non-citizens can still get SNAP if someone in the household is an eligible non-citizen or a U.S. citizen. Even undocumented parents can apply for SNAP on behalf of their citizen children.

There is an immigration reporting requirement in the SNAP Law that makes some families with undocumented members reluctant to apply. The law requires the state SNAP agency to report “aliens it knows to be unlawfully present” to USCIS. However, SNAP offices in NYS have been instructed to report only those individuals who present evidence of a USCIS determination that they are not here lawfully.

Practically speaking, this means the SNAP office has no duty to report someone unless the person shows the SNAP office that s/he has a final Order of Deportation or has submitted falsified immigration documents. It is also important to note that the SNAP office is not to make the report directly to USCIS, but is simply required to give the name of the person with the Order of Deportation to OTDA.

USCIS has made it clear that receiving SNAP benefits does not make a person a public charge. Households with non-citizens should be reassured that if they receive SNAP benefits the non-citizen member should be able to adjust their status (apply for permanent residence or citizenship).

To view the USCIS Public Charge Fact Sheet visit http://www.uscis.gov/

Although the law has been very favorably interpreted concerning how SNAP households with non-citizen members should be treated, no one can ever guarantee that proper procedures will always be followed. It cannot be stressed highly enough, though, that LDSS employees only have authorization to report the names and addresses of non-citizens who have final deportation orders and those with falsified immigration documents. However, even in these circumstances, any reporting would be made to OTDA, not to USCIS. There is no authority for SNAP workers to contact Immigration directly except to verify immigration documents that are presented by the applicant to support the applicant's eligibility for benefits. If an eligibility worker threatens to report a non-citizen member of an applicant household to USCIS in order to get them to withdraw their application, this is a violation of the Civil Rights Law and should be brought to the attention of the supervisor, the Commissioner, or OTDA.

Fleeing Felons and Probation Violators (GIS 10 TA/DC026)

People who have felony warrants pending against them (fleeing felons), and people in violation of probation may be identified by computer matches and denied SNAP. However, in all these cases, other household members may continue to be eligible for SNAP and special budgeting rules apply.

OTDA clarified with SNAP offices that they must NOT discontinue SNAP benefits for anyone with a warrant based on an alleged probation or parole violation. These types of warrants do not constitute a determination of a violation but, instead, are allegations of a violation.

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WORK REQUIREMENTS (NYS Temporary Assistance and SNAP Employment Manual, Section 3; Appendix I; GIS 12

TA/DC035) SNAP has an employment and training component. Unless they are exempt, adults must participate in some type of work or training activity to receive SNAP. However, there are many people who are exempt and have no further obligation to participate in work activities. A SNAP participant is exempt if he or she is: • under 16 • 60 and over • age 16 or 17 and not the head of the

household • attending school, training, or college on

at least a half-time basis Note: College students between the ages of 18 and 49 must meet the student eligibility criteria listed on pp. 22-24.

• working at least 30 hours/week or earning weekly pay of at least 30 times the hourly federal minimum wage

• a migrant or seasonal farm worker under contract to begin work within the next 30 days

• meeting TANF work requirements • receiving unemployment benefits • participating in a drug or alcohol

treatment program • taking care of a child under 6 or an

incapacitated person • jointly applying for SNAP and SSI and

awaiting an SSI eligibility determination • physically or mentally unable to work

(less documentation is required than for being disabled - generally doctor’s or other health care provider certification is sufficient)

In NYC the following exempts an individual from the work rules: • Pregnancy • Participating in a refugee training program at least half time

Anyone who is not exempt must comply with the SNAP office’s work requirements once they are receiving SNAP. This usually involves attending an evaluation appointment with an employment office at the SNAP office, providing information about education and work history, and then participating in an assigned work program. Work programs typically include workfare, job search, “job clubs,” GED programs, and, occasionally, training or other educational activities. If the local district does not assign a work activity, the participant is still eligible to receive SNAP. Individuals who must comply with work requirements cannot be required by their SNAP office to spend more than 120 hours per month participating in employment and training activities. This includes:

• job search • classes • work programs • workfare • paid work

• any work the individual is doing for something other than money (such as work they do in exchange for free housing or free meals)

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Workfare cannot exceed the value of the SNAP (and cash assistance for people receiving both) divided by the minimum wage.

If a participant fails to comply with work requirements, voluntarily quits a job without good cause, or fails to meet cash assistance work requirements, they can be “sanctioned,” or made ineligible to participate for a period of time. The sanction disqualifies only the individual, not the whole household. If there are other people in the household who are still eligible, the SNAP case will stay open and the sanctioned person should request to be restored to the case at the end of the sanction period. If there are no other eligible participating household members, the sanctioned person will have to reapply for benefits the month before the sanction ends in order to receive SNAP benefits again. Voluntary Quit (NYS Temporary Assistance and SNAP Employment Manual, Section 13; Appendix I) The “voluntary quit” rule is an attempt to prevent people from deliberately making themselves poor so they can get SNAP. The rule disqualifies such people from receiving SNAP for a specified length of time (called a sanction period) of two months or longer. In reality, this usually arises when someone quits their job for some other reason, such as a decision to relocate, and immediately applies for SNAP. This rule should not be a major problem, although SNAP offices frequently question the reasons for leaving a job. All the applicant has to show is that there was some valid reason for leaving the job. This will prove “good cause” for leaving the job and satisfy the rule. Applicants who were fired did not quit for SNAP purposes -- it does not matter why they were fired. The NYS Temporary Assistance and SNAP Employment Policy Manual states that “provoked discharge” termination situations in which an employee causes him/herself to be fired are not subject to a voluntary quit disqualification. The voluntary quit rule is frequently misapplied because the cash assistance program rule is different. Those without a valid reason for quitting their job may or may not be subject to a voluntary quit sanction. It is important to remember that there are many people who are exempt from the voluntary quit rule. See the SNAP Work Rules Desk Guide (Appendix I) for further details on the voluntary quit rules. Able-Bodied Adults Without Dependents (ABAWDs) (NYS Temporary Assistance and SNAP Employment Policy Manual, Section 3; Appendix I; 14-52-ELI) Many unemployed adults without children – called Able-Bodied Adults Without Dependents (ABAWDs) – may have to meet a time limit requirement as well as the “regular” SNAP employment and training rules. The general rule is that ABAWDs can receive SNAP for only three months in three years, unless they meet certain work-related criteria. USDA has provided NYS with a waiver of the ABAWD requirements until December

An ABAWD is a person between 18 and 49 years old who is not disabled and who lives in a SNAP household without any children under 18.

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31st, 2015. USDA granted waivers to states based on their eligibility for extended unemployment benefits. Through December 2015, no county in New York State is applying ABAWD requirements. Beginning on January 1, 2016, many counties in New York will need to re-instate the ABAWD time limits. Local Districts will be made aware of the policy changes and will be notified if they meet a waiver or if they will need to begin evaluating SNAP applicants/participants using ABAWD rules. Hunger Solutions New York will provide additional information on the re-instatement of the time limits in NYS as policy information from OTDA is released. Please check our website for policy updates and new resources, and to register for upcoming webinars. Work Sanctions, Intentional Program Violations (14-ADM-06; GIS 13 TA/DC048; GIS 13 TA/DC005; GIS 12 TA/DC035) People who do not comply with work requirements, or who are found to have committed an Intentional Program Violation (IPV), will be removed from the household SNAP case for a period of time specified by the SNAP office. The SNAP Work Rules Desk Guide (Appendix I) has a summary of SNAP employment and training rules.

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HOUSEHOLD COMPOSITION (SNAPSB Section 5: pp. 48-52; Appendix M, LDSS-4314; 08-ADM-04)

A SNAP household is defined as:

• People who live together and • Purchase and prepare meals together

Why is household composition important when prescreening for SNAP eligibility?

• Individuals included in a SNAP household must have their income included when determining eligibility and calculating the budget.

Some people are “mandatory” household members. This means that if they are living in the same house, they MUST BE INCLUDED IN THE SNAP HOUSEHOLD, EVEN IF THEY ARE NOT PURCHASING AND PREPARING MEALS TOGETHER. Mandatory household members include:

• Spouses; • Parents (natural, adoptive or step-parent) and

their children under 22; AND • Children under 18 under parental control of a

person other than a parent. (See chart on next page for additional details.)

Other people can apply for SNAP as their own household, as long as they are purchasing and preparing their meals separately. See the Household Composition Guide on the next page for a step-by-step guide to determining household composition. Special Rules for Homeless Youth, Foster Care Children, and Boarders SNAP regulations do not have an age requirement in most cases for homeless youth. Any homeless youth under the age of 22 can apply for SNAP as long as they are not residing with their parents and are not under “parental control” of another person. They do not need to be included in a parent’s SNAP case unless they live together. A homeless individual must apply as a household with the other people that they are living with, if they regularly buy and prepare food together. See GIS 13TA/DC043 for more information. Boarders and foster care children may be either included in or excluded from the SNAP household of the landlord or foster parents at the household’s option. It is important to note that foster care income (in excess of allowable, verified, reimbursable expenses) is counted as unearned income when the foster child is included in the SNAP household. If a foster care child is not included in the SNAP household, then the foster care income is exempt. Adopted children must be included in the SNAP household and adoption subsidies (in excess of allowable, verified, reimbursable expenses) are counted as unearned income. See income chart on pg. 37 of this guide.

If a person living in the same house or apartment with an applicant is not a member of the applicant’s SNAP household, that person’s income and resources are completely ignored. On the other hand, people who are not living together are not part of the same SNAP household, even if they are married or have other legal relationships to each other.

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Special Rules for Severely Disabled People Living With Others A disabled individual who lives with others might not be able to purchase and prepare his/her own meals because of a severe medical condition. However, this person may still be able to establish separate household status if s/he fits into one of two groups:

1. The person’s food is being purchased and prepared separately from the people they live with.

2. The food is not being purchased and prepared separately, but the person is both

elderly AND disabled, and the income of their “housemates” (those purchasing and preparing the food for everyone) does not exceed 165% of the federal poverty level.

For 10/01/15 – 9/30/16 – 165% of Poverty – Elderly/Disabled Separate Household

H.H. Size

1 2 3 4 5 6 7 8 Each Additional Person

165% of FPL

$1,619 $2,191 $2,763 $3,335 $3,907 $4,479 $5,051 $5,623 +$572

HOUSEHOLD COMPOSITION GUIDE To determine who is included in a SNAP household, ask the following questions:

1. Are all of the people living in the same apartment/house?

YES - Go to #2 NO - You are a separate SNAP household

2. Do you usually purchase and prepare food together? YES - You are all one household NO - Go to #3

3. Are the other people in your home, who do not purchase and prepare food with you, family relations? (Example: spouse, children, parents, and sisters/brothers) YES - Go to #4 NO - They are not part of your SNAP household (they may

apply for SNAP separately).

4. Relatives have to be part of your household for SNAP purposes if they are: • Spouses living together

• Parents and children under age 22 who live together even if the child has their own minor child(ren) and/or spouse living with them.

• Children under age 18 living with and under the “parental control” of an adult other than their parent/stepparent. (For information on how “parental control” is determined, see 07-INF-14 Child-Only Questions and Answers pg. 11., question 41, and SNAPSB Section 5: pp. 50 c. + note)

OTHER RELATIVES WHO MAY BE SEPARATE SNAP HOUSEHOLDS (If they purchase/prepare food separately):

• Adult brothers & sisters living together • Adult children, 22 or older, living with parents • Cousins, uncles/aunts, and other distant relatives

In cases where there is a joint custody situation, see the SNAPSB Section 5: pg. 48.

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EXPANDED CATEGORICAL ELIGIBILITY/RESOURCES (SNAPSB Section 16; 07-ADM-09; 09-ADM-06; 10-INF-07; GIS 12 TA/DC001;

Appendix J) Expanded categorical eligibility is granted to most households applying for SNAP. Households granted categorical eligibility will be budgeted differently. These families:

• Do not need to pass a resource test • Do not need to pass a net income test, and • May be able to use higher income levels for eligibility, depending on the household

type: o Households with an elderly and/or disabled member – 200% for Gross

Income Test (GIT) o Households with dependents care costs – 200% for GIT o All other households – 130% for GIT

Poverty Guidelines Chart

Households with Dependent Care Costs: Households with out-of-pocket dependent care costs, which are categorically eligible for SNAP, can use 200% of poverty when testing gross income. Households are eligible to deduct out-of-pocket daycare expenses when all adult members are:

• Working or needing daycare to continue work • Looking for work • Attending employment training programs (not limited to FSET, UIB job

search…), or • Pursuing education that is preparatory to employment

This language can be found in the SNAPSB Section 11: Standards and Deductions pg. 251.

Family Size 130% of Poverty Monthly Income

Oct. 1, 2015 – Sept. 30, 2016

200% of Poverty Monthly Income

Oct. 1, 2015 – Sept. 30, 2016

1 $1,276 $1,962

2 $1,726 $2,655

3 $2,177 $3,348

4 $2,628 $4,042

5 $3,078 $4,735

6 $3,529 $5,428

7 $3,980 $6,122

8 $4,430 $6,815

Each Additional Person

+ $451 + $693

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Households That ARE NOT Categorically Eligible: Most households which are income eligible for SNAP are also categorically eligible. However, there are still a small number of households which cannot be considered categorically eligible and must have their resources and net income considered as part of the application process. These include:

1. Households with members who have been disqualified from SNAP due to an IPV or other sanction.

2. Households with an elderly or disabled member whose gross income is above 200% of poverty per household size.

These households may still qualify under regular SNAP rules:

• Resources would need to be considered. • Gross income must be at or below 130% of poverty for household size if no one is

elderly /disabled. • Net income must be at or below 100% of poverty for household size. • Households with an elderly/disabled member do not need to meet a GIT. Net

income would need to fall at or below 100% of poverty. Appendix J of this guide is the “Expanded Categorical Eligibility Desk Guide” which aids in determining whether a household is categorically eligible for SNAP. What resources count if a household is not categorically eligible?

Households which are not categorically eligible have a $2,250 resource limit if no one is elderly or disabled, and $3,250 if there is an elderly or disabled household member.

Resources are everything owned by the people in the household. This includes cash, bank accounts, stocks and bonds, lump sum payments received, and real estate. Things the household has on hand, but does not own, do not count.

Any resource owned by a non-categorically eligible household counts toward the household’s resource limit, unless it is exempt. There are many exemptions from the resource rules. The most common exemptions are:

• One licensed vehicle for each adult household member (Additional licensed vehicles used by children under 18 to attend school, training, or work are also exempt.)

• One house (if the household lives in it) • Life insurance • One burial plot per person • Earned Income Tax Credits (EITCs) • Inaccessible resources

For a complete list of exempt resources, see SNAPSB Section 17. Remember, resources are not counted at all if the household is categorically eligible.

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“Tax Preferred” Retirement Accounts such as Keogh Plans, IRAs, Simplified Employer Plans, Profit Sharing Plans, and Cash Balance Plans are excluded from countable resources for any household subject to the resource limits. “Tax Preferred” educational accounts such as 529s and Coverdell educational savings accounts are also excluded from countable resources for any household subject to the resource limits. See OTDA’s 08-ADM-09 for more information.

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CALCULATING A BUDGET (SNAPSB Sections 11, 12 & 13; GIS 14 TA/DC011, 018, 023, 033; Appendix K)

Overview of Budgeting SNAP budgeting is complicated when compared to budgeting for other means- tested programs. This is the result of an effort to carefully target the benefits to the neediest households. This section is intended to guide advocates through the process of estimating the SNAP benefit for which a household might be eligible. If it appears that the household may be eligible for benefits, the household should be referred to their Local Department of Social Services (LDSS) to apply for SNAP. The line numbers in the following narrative correspond to the budget worksheet in Appendix K. The SNAP budgeting section explains how to determine an estimated SNAP budget using the attached worksheet (Appendix K). Please note that Hunger Solutions New York’s web site has SNAP Budget Estimator Tools that can be downloaded for use. Unlike the paper budget worksheet, these tools do some of the math for you. There are several determinations that must be made in the SNAP budgeting process before a budget can be calculated:

1. Determine which household members are eligible for SNAP benefits and are applying together.

2. Add up all income from earned and unearned sources to determine the household’s gross income.

3. Determine if the household is categorically eligible, and if so, which gross income test must be applied.

4. Test the income against the correct percent of poverty for household size. If the household is below the income listed you can start the budgeting process.

All budget calculations should be considered estimates. Many factors can affect each aspect of the budget, and there are an equal number of opportunities for inaccuracies. In particular, reported income used in the calculation may change or may be the applicant’s own estimate. Therefore, it is important to emphasize to the applicant that you are providing them with an estimate of the SNAP benefits for which the household may be eligible. If the allotment ultimately granted by the SNAP office is significantly different, the applicant or advocate should read the budget explanation in the notice carefully to determine where the difference occurred. If the SNAP office has made an error, it should be corrected.

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Household Information To accurately calculate the household’s SNAP budget, you will need the following household information:

• Household composition • Age of household members • Disability status of household

members • Amount and source of income • Daycare costs

• Child support paid • Medical expenses for elderly or

disabled household members • Shelter costs • Type of shelter • Utility costs

For SNAP purposes,

• “Elderly” means 60 or older. • “Disabled” means receiving a federally related disability benefit such as:

o Supplemental Security Income (SSI) o Social Security Disability (SSD) o Disability-related Medicaid o VA Disability 100%

For details see the SNAP Sourcebook Section 5, pp. 56-67. Using the SNAP Budget Worksheet Earned vs. Unearned Income (SNAPSB Section 13) It is important to know whether income is earned or unearned, since a 20% deduction from the earned income will be taken on Line 6. This deduction makes a big difference in the final SNAP allotment amount. If income is incorrectly classified, the resulting budget will be wrong. Income of Non-Household Members (SNAPSB Section 13: pg. 272) The income of people who are not part of the SNAP household does not count. However, the income of people in the household who are not included in the household because they are ineligible for SNAP, may count. Income of ineligible students does not count, while the income of sanctioned individuals is counted. Income of ineligible non-citizen household members is prorated. See the Advanced Budgeting chapter for more details.

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These are some of the most common sources of income -- this list is NOT exhaustive:

* See 08-ADM-04 for more information on what an allowable, verified, reimbursable expense (things that do not count as income) is for adopted and foster children included in the SNAP household.

** Social Security beneficiaries and SSI recipients with a my Social Security account can go online and easily view, print,

or save an official benefit verification letter instantly. Individuals 18 and older can sign up for a my Social Security account at www.socialsecurity.gov/myaccount. For more information see GIS 13 TA/DC010.

Earned Income

Unearned Income

• Gross wages from work (including income from part time work of high school/GED students who are age 18 or over)

• Self-employment earnings (minus the cost of doing business)

• Gross income from rental property (minus the cost of doing business) in which a household member is engaged in management for at least 20 hours a week

• Payments from boarders/lodgers (excluding related costs incurred)

• Youth Opportunity Program payments

• Earnings from the Workforce Investment Act (WIA) for household members over 18 (if under 19, the earnings are not counted)

• Training allowances, to the extent they are not a reimbursement from the TA or SNAP

• VISTA income (however, if the household was on SNAP or TA when they entered VISTA, then the VISTA income is not counted

• Wages earned by a household member that are garnished or diverted by an employer (except court-ordered child support)

• Adoption subsidy*

• Alimony payments

• Annuities

• Any portion of Veterans Administration scholarships for general living expenses (the remainder is excluded) – all other higher education scholarships, loans, and grants are excluded including work study income

• Child support payments received (including any TA “pass-through”)

• FEMA payments to homeless in absence of major disaster

• Foster care subsidy if child is included in the household*

• Monies and dividends paid from trusts, interest, and royalties

• Pensions

• Short-term disability payments

• Social security retirement, survivors’ benefits, SSI, SSD**

• Strike benefits

• Temporary assistance payments (TANF)

• Veterans’ benefits including VA Aid and Assistance (14-INF-10)

• Worker's compensation and unemployment benefits

• Any other direct money payment that represents a gain or benefit not falling under an exemption

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WHAT DOES NOT COUNT AS INCOME FOR SNAP?

(These are some common sources NOT countable as income -- this list is NOT exhaustive)

• Allowances, earnings, or payments to Workforce Investment Act program participants • Annual school and daycare clothing allowances, regardless of method of payment • Child support collected and not passed through to household by Child Support • Cost of producing self-employment income • Earned Income Tax Credits (EITC) and all other tax credits -- Federal and State (13-ADM-02) • Earnings from On the Job Training (OJT) training if under 19 years old • Earnings of child under 18 who attends high school or GED • Educational loans, grants, scholarships for tuition, and mandatory fees (except portion of Veterans

Administration scholarships earmarked for general living expenses – these are treated as unearned income)

• Home Energy Assistance Program (HEAP) payments • H.U.D. housing subsidies (e.g., Section 8 vouchers, Housing Authority unit subsidies) • Housing provided to employee by employer • Income from reverse mortgages (unless there is a cash-out option) • Income of persons who are not members of the SNAP household • Income Tax refunds, rebates, and credits – Federal and State (GIS 14 TA/DC044) • Income under Title V of the Older Americans Act • Individual Development Account (IDA) contributions • In-kind income (things of value that are not cash) • Insurance policy dividends • Interest from funeral agreements or funds • Irregular or infrequent income less than $20 per month • Legally obligated child support paid on behalf of child(ren) not living in the household

• Loans (including educational) • Lump sum or one-time payments • Military combat pay • Monies for care and maintenance of third-party beneficiary who is not in the household • National Community Services Act income (AmeriCorps) • Non-cash benefits from other federal programs such as WIC or School Meals • Payments made on behalf of a household member to a third party (vendor payment) (except

payments made as part of a cash assistance grant, including Jiggetts payments) • Payments specifically exempted by federal law (i.e. to Hmong refugees, Aleuts, World War II-

related payments, etc.) • Payments to relocate • Payments to volunteers under Title II of the Domestic Volunteers Services Act (i.e., RSVP, Foster

Grandparents, Senior Companion, and senior health aide programs) • Private charity income under $300 in three months • Public Assistance Restaurant Allowances by voucher or direct to vendor • Reimbursements for other-than-normal non-living expenses, e.g. medical, special work clothes, car

use for work • Reimbursements for training-related expenses • SSI PASS account income • Work study income funded through the Higher Education Act • VISTA income, but only if the household had been on TA or SNAP when they entered VISTA (05-

ADM-14)

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BUDGET WORKSHEET (See Appendix K; GIS 13 TA/DC038)

Income (SNAPSB Section 12 & 13; 02 ADM 07) SNAP defines one month as 4.33 weeks. Calculate monthly income as follows:

- If income is received weekly, multiply by 4.33 (e.g., work income, UIB) - If income is received every other week, multiply by 2.17 - If income is received twice per month, multiply by 2 (work income, PA)

Line 1. Gross monthly earned income – Gross monthly income is your income from earned sources before any deductions, such as taxes, FICA, health benefits, or union dues are taken out. All the income received by every member of the SNAP household counts, unless it is specifically exempt. This includes the income of children, unless the child is under 18 AND a student. Only earned income goes on Line 1. Line 2. Gross monthly unearned income – Monthly unearned income is the total household income from unearned sources. Line 3. Gross income -- Add Lines 1 and 2. This is the household’s monthly gross income, earned and unearned combined. Line 4. Child support paid – Enter the amount of any legally obligated child support paid by a household member. Legally obligated health insurance payments for children and court-ordered arrears can be included. Use the same methodology described in the earned income section (Line 1) to convert weekly payments into a monthly total. (02 ADM 07) Line 5. Adjusted gross income -- Subtract Line 4 from Line 3. This is the household’s countable monthly gross income. The Maximum Gross Monthly Income limit is set at:

• 200% of the federal poverty level for households with elderly or disabled members, or who pay out-of-pocket daycare expenses, or

• 130% of the federal poverty level for all other households. • Households without an elderly or disabled member whose adjusted gross income

exceeds the correct GIT are NOT eligible for SNAP. • Households with at least one elderly (age 60+) or disabled member who exceeds

200% GIT, or who are not categorically eligible, do not have to meet a GIT. Do not apply this limit to these households; continue with the budgeting process.

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Household Size and Gross Monthly Maximum Incomes (October 1, 2015 - September 30, 2016):

H.H. Size 1 2 3 4 5 6 7 8 Each

Additional Person

130% of FPL

$1,276 $1,726 $2,177 $2,682 $3,078 $3,529 $3,980 $4,430 +$451

200% of FPL

$1,962 $2,655 $3,348 $4,042 $4,735 $5,428 $6,122 $6,815 +$693

Deductions (SNAPSB Section 12)

Line 6. Earned Income Deduction – Multiply Line 1 (earned income) x .2. The earned income expense deduction is twenty percent (20%) of the gross wages, salary, or self-employment income.

Line 7. Standard Deduction – Enter amount from chart below.

Standard Deduction Amounts (October 1, 2015 - September 30, 2016):

Household size 1-3 people 4 people 5 people 6 or more people

$155 $168 $197 $226 Line 8. Child/Dependent Care – The actual cost for care of each child/dependent household member due to work (including households looking for work or attending employment and training programs) or school responsibilities can be deducted. This deduction can be applied to the care of a disabled adult household member if necessary. (08-ADM-09)

Line 9. Homeless Household Shelter Deduction – SNAP households that have no fixed and permanent address can take a deduction of $143 per household, in lieu of actual shelter costs. See the section on Advanced Budgeting for more information. Line 10. Medical Expense Deductions for Elderly and Disabled applicants only – All non-reimbursable medical expenses incurred by elderly or disabled household members can be deducted, except for the first $35/mo. This includes cost of transportation to medical appointments, over the counter medications purchased pursuant to the instructions of a medical professional, prescriptions not covered by insurance, and co-pays. Unpaid medical bills can be included. Medical expenses of other household members cannot be included. For more details about what types of medical expenses can be included as deductions, see the worksheet on the next page.

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SNAP MEDICAL EXPENSE DEDUCTION WORKSHEET

SNAP law permits people who are elderly (age 60+) or disabled to deduct from their income all out-of- pocket medical costs greater than $35 per month – the first $35 is not deductible. Below: Enter monthly estimated, anticipated non-reimbursable out-of-pocket medical expenses

for each household member who is elderly (60+) or medically disabled. $ Medical and dental care, including psychotherapy and rehabilitation services. $ Hospitalization or outpatient treatments, nursing care, and nursing home care. $ Prescription drugs, over-the-counter medications approved by a licensed

practitioner, costs of medical supplies, sickroom, or other prescribed equipment. Unfortunately, the costs of special diets are not allowed as a medical deduction.

$ Health and hospital insurance policy premiums, including Medicare, Medicaid

and private medical insurance premiums, co-payments, and deductibility. This includes, but is not limited to, "spend-down" expenses incurred by Medicaid recipients.

$ Payments to maintain an attendant, home health aid, child care service, or

housekeeper necessary due to age or illness (includes reasonable cost of food eaten in the home by caretaker).

$ Costs of transportation and lodging to obtain medical treatment and services.

Households who drive their own vehicle should use the IRS medical mileage rate - currently 23 cents per mile. The SNAP office is encouraged to use the LDSS mileage reimbursement rate set for county employees, but only if it is higher than the IRS rate above.

$ Medical supplies and equipment, including eyeglasses, dentures,

hearing aids, and prosthetics. $ Cost of securing & maintaining a seeing eye, hearing, or service dog

(including food costs for dog). $ Unpaid medical bills. ══════════════════════════════════════════════════════════════ $ Subtract $35 = $ Monthly Medical Expense Deduction

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Line 11. Add Lines 6 through 10 to determine the total non-shelter deduction. Line 12. Subtract Line 11 (deductions) from Line 5 (adjusted gross monthly income) to get the money assumed to be available for shelter costs and food. Shelter Expenses (SNAPSB Section 12; GIS 14 TA/DC 018; GIS 14 TA/DC023) Line 13. Actual Rent or Mortgage – this is the actual monthly rent or mortgage payment incurred by the household for the home in which it lives. If the household has multiple mortgages, or other loans for which the home was used as collateral, such as home equity loans, they can all be included. Clarification has been made by OTDA stating that homes that are in foreclosure and households facing eviction proceedings continue to have an allowable shelter deduction as long as the cost is incurred. Mortgage costs, homeowners insurance, property taxes, and rent remain as allowable shelter expenses even if they are not being paid, including during foreclosure and eviction processes. If there are non-household members living with the SNAP household, use the share of the rent or mortgage actually paid by the SNAP household. Do not include the non-household member’s share. For example, if two families share a house and each family pays half the rent, the applying household can only deduct their half of the rent as a shelter cost. Some households take in roomers to help cover their rent or mortgage expense. Local districts should generally treat these situations as “shared living” arrangements, meaning that the roomer’s share of rent would not count as income to the household – even if the roomer is paying his share of the rent or mortgage directly to the household. However, the roomer’s share of rent would not be included in the household’s shelter deduction. (SNAPSB Section 5, p. 52,55) Line 14. Standard Utility Allowance (SUA) SNAP households living in New York may receive one of three possible Standard Utility Allowances (SUA) depending on their type of housing and where they live in NYS. In all cases the standardized allowance is used, rather than the household’s actual utility expense – even if the household’s actual expenses are higher than the standard. The SUA is never prorated. Households in shared living situations and households with ineligible members can still receive a full (non-prorated) SUA. Using the wrong SUA can result in dramatically miscalculating a household’s benefits. LEVEL 1. Combined Heat, Utility, and Phone Allowance. Anyone who pays his or her own heating or cooling costs or owns their own home is eligible for the Level 1 deduction. Anyone in receipt of a $21 or more Home Energy Assistance Program (HEAP) benefit in the month of application or in the immediately preceding 12 months is also eligible for the Level 1 SUA deduction. Previously, “potential eligibility” for HEAP allowed for an automatic Level 1 SUA. Households that are potentially eligible for HEAP will no longer be credited with a Level 1

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SUA until they are in actual receipt of at least a $21 HEAP payment. See GIS 14 TA/DC023 for more information. The following SNAP households are ineligible to receive the Level 1 SUA:

• Households that are renting that are not paying a heating/cooling cost separate from their rent and have not received a HEAP benefit of $21 or more in the month of application or in the preceding 12 months

• Households that are living in a shared living situation in which no adult in any SNAP household in the domicile has received a HEAP benefit of $21 or more in the month of application or in the preceding 12 months

• Un-domiciled (households getting the homeless deduction (Line 9) – they’re not eligible for a SUA)

• Households in domestic violence or homeless shelters (they get Level 3) LEVEL 2. Combined Utility and Phone Allowance. Any household that is not eligible for Level 1, but can show some non-heat utility cost (like electricity not used for heating, water, sewage or trash collection) is eligible for Level 2. LEVEL 3. Phone Allowance Only. This is for households that have no other utility costs, but do have a telephone. This allowance is automatically provided to households not eligible for Levels 1 or 2 (except for homeless households receiving the standard homeless deduction – they cannot receive a separate SUA).

Line 15. Other Shelter Expenses – Other expenses related to shelter can be deducted here. This includes taxes, homeowners insurance, and condo fees. (You should use a standard figure of 55% of the homeowners’ insurance premium, unless you can determine the portion of the premium cost attributable to insurance on structure of the home.) Routine home maintenance cannot be deducted, and repairs can be deducted only if the damage was the result of a disaster (such as fire or flood). Line 16. Total Shelter Costs – Add Lines 13, 14, and 15 to get the total shelter cost.

Standard Utility Allowances for NYS (Effective 10/1/15)

Level 1 Level 2 New York City $768 $304 Nassau & Suffolk Counties $716 $281 Rest of State $636 $257 Level 3 (Telephone SUA for all counties) -- $33

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Excess Shelter Deduction

The concept of “excess shelter costs” is unique to SNAP. It assumes that certain percentages of the household’s income should be allocated to pay shelter costs. Households with particularly high shelter costs relative to their income (excess shelter costs) are assumed to not have as much money left for food, and so are allowed to deduct the “excess” portion of their shelter costs. However, the amount of excess shelter cost that can be deducted is capped at $504. This “excess shelter cap” does not apply to households with an elderly or disabled member. Any household including an elderly or disabled person can deduct the entire excess shelter cost. This is a very important difference, which results in significantly higher benefit amounts for most households categorized as elderly or disabled.

Calculating the Excess Shelter Deduction Line 17. Divide Line 12 (income available after other deductions) by 2. Half of the income left after the other deductions is considered to be theoretically available to cover housing costs. Line 17a. Calculate the Excess Shelter Deduction. Subtract Line 17 (total shelter cost) from Line 16 (amount theoretically available for housing). The result is the excess shelter cost. If it is a negative number, enter zero here. For elderly/disabled households, enter the actual amount on Line 17a. For all other households, if Line 17a exceeds $504, enter $504 (the amount of the Excess Shelter Cap); otherwise enter the actual amount. Calculating the SNAP Benefit Allotment Line 18. Net SNAP Income – Subtract Line 17a (excess shelter deduction) from Line 12 (income after other deductions). Categorically eligible households do not have to pass the net income test although you still input the income information and continue through the budget worksheet process. Although the net income test doesn’t apply to categorically eligible households, not all categorically eligible households will be able to receive SNAP. See Line 21 below for more information. For households who are not categorically eligible for SNAP, the net income amount must be under 100% of poverty in order for the household to be SNAP eligible. If this amount is over 100% of poverty, the remainder of the calculation will result in an allotment of zero. If the amount is a negative number, the net SNAP income is $0.

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Household Size and Net Monthly Maximum Incomes (October 1, 2015 - September 30, 2016)

These income limits do not apply to categorically eligible households

Line 19. Thrifty Food Plan Amount (Maximum SNAP Allotment for HH size) – The maximum benefit allotment is based on the Thrifty Food Plan, a theoretical idea of the costs of feeding a household. Determine the maximum allotment for the eligible household members by looking at the correct chart below. Enter the maximum allotment on this line. Do not include ineligible members, such as ineligible aliens or sanctioned household members.

Maximum SNAP (Thrifty Food Plan) ALLOTMENTS by Household Size (October 1, 2015 - September 30, 2016):

H.H. Size 1 2 3 4 5 6 7 8 Each

Additional Person

Maximum Allotment

$194 $357 $511 $649 $771 $925 $1,022 $1,169 +$146

Line 20. SNAP Budget Income – Multiply Line 18 (Net Income) x .3 – Thirty percent of the household’s net income is assumed to be available for food purchases, and is deducted from the maximum SNAP allotment. Line 21. Estimated SNAP Benefit – Subtract Line 20 (30% of net income) from Line 19 (maximum allotment) – This is the estimated SNAP benefit for the household. The minimum SNAP benefit issued to all eligible one- and two-person households is $16 through September 30, 2016. If the estimated SNAP benefit for a one- and two-person household falls between $1-15, the household should be eligible for $16 per month through September 30, 2016. If the estimated benefit is zero or a negative number:

• One-and two-person households will get the $16 minimum benefit. • Households of 3 or more will not be eligible for any SNAP benefits.

H.H. Size 1 2 3 4 5 6 7 8 Each Additional

Person

100% of FPL

$981 $1,328 $1,675 $2,021 $2,368 $2,715 $3,061 $3,408 +$347

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ADVANCED BUDGETING

Income of Ineligible Household Members Some members of a household may be ineligible for SNAP because of their immigration status, sanctions relating to previous participation in the program, or because they are students or participating in a job action. In most cases, though, some or all of the income of household members ineligible for SNAP is counted in the SNAP budgeting process. Hunger Solutions New York has SNAP Benefit Estimator tools available for download on our website. These tools are designed to help estimate the SNAP allotment for households with ineligible members. Unlike the paper budget worksheet (found in Appendix K of this guide), these tools do the math for you, including prorating for ineligible members. Budgeting for Non-Citizens (SNAPSB Section 13: pp. 267 - 271; 03-INF-14) Budgeting income for households with ineligible non-citizen member(s):

The income of people ineligible due to immigration status is prorated proportionate to the number of people being included in the SNAP case. Thus, if there are three people in the household and two are eligible to receive SNAP, two-thirds of the ineligible person’s income would count as income for the SNAP household. Thus, to determine the amount of income to be budgeted:

1. Divide the income by the number of people in the household. 2. Multiply the result by the number of people in the SNAP case.

(see the formula below)

The result is budgeted as income to the SNAP household, with earned income receiving the earned income deduction.

However, if an eligible household member earns the household’s income, the full amount is budgeted. There is no prorating to allow for the presence of the ineligible household members. Resources of ineligible non-citizens are counted in their entirety – not prorated. If a sponsored non-citizen is eligible for SNAP, the income of a non-household member who sponsored a non-citizen may be counted. This “sponsor deeming” applies only to sponsor agreements entered into since December 1997.

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Very few non-citizens should be subject to sponsor deeming. Sponsor deeming does not apply to:

• Refugees • Asylees • People with deportation withheld • LPRs with 40 qualifying quarters, or • LPRs who are indigent (whose gross income, including any income provided by the

sponsor, is below 130% of the federal poverty level) Additionally, sponsor deeming does not apply if:

• The sponsor is a part of the SNAP household • The sponsor is ineligible for SNAP based on immigration status, or • The sponsored non-citizen is a battered spouse or dependent

In addition to the sponsor deeming requirement, there is also a “sponsor liability” rule for non-citizens whose sponsors entered into a sponsor agreement since December 1997. Under the sponsor liability rule, the sponsor may be held liable for – and asked to repay – the value of any SNAP benefits issued to the sponsored non-citizen. However, in New York State, even though the LDSS may request reimbursement from sponsors, OTDA has indicated that no legal action will be pursued against sponsors for repayment. Deductions for Households with Ineligible Non-Citizens The shelter and dependent care expenses billed to or paid by the ineligible household member are prorated in the same manner as income. The amount of actual expenses paid by the eligible household members can be deducted. The household receives a full standard utility allowance (SUA). Budgeting Shelter Costs for Homeless People Homeless Shelter Deduction The Homeless Shelter Deduction can be applied to families who are not living in a shelter or receiving free shelter for the entire month. These households are assumed to be incurring a shelter cost and the applicant does not need to prove actual shelter expense to receive this deduction. If the Homeless Shelter Deduction is used in budgeting, the household is not eligible to receive a SUA of any level. However, if actual shelter costs can be verified and they are more than the standard Homeless Shelter Deduction ($143), then the regular shelter deduction will be used. Regular Shelter Deduction If the family is incurring any actual shelter costs which they can document (ex: paying to stay with family/friends) and these expenses are greater than the Homeless Shelter Deduction ($143), then the actual shelter costs will be deducted. Another example would be a homeless household that is living in their car and making a car payment. If the car payment is more than the standard Homeless Shelter Deduction ($143), then this would

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be considered the household’s actual shelter deduction. When using a regular shelter deduction, families and individuals would be eligible for at least a Level 3 SUA ($33), possibly more depending on what their financial contributions to the dwelling are. Other Deductions Child support can be deducted, as well as medical deductions for elderly/disabled households and daycare costs for most families. Budgeting Rules for Other Groups Sanctioned People The full income of a person sanctioned due to work rule violations or disqualified due to IPV is budgeted, and all deductions may be taken. Therefore, the budget is calculated as if the sanctioned person were participating, except that the household size is reduced in determining income eligibility and SNAP allotment amounts. Resources of sanctioned people are counted in their entirety. Students Ineligible students are invisible to the SNAP case. Their income and resources do not count. Self-Employment Income (SNAPSB Section 13 pp. 282-285) What is Self-Employment Income? Self-Employment Income is the income received from a self-employment enterprise. Some examples of self-employment enterprises include:

• Payments from rental income o Managed 20 hours or more each week counted as earned income o Managed less than 20 hours a week counted as unearned income

• In-home daycare provider • Running own business

For most self-employment households this income is meant to support them throughout the year. In this case you would:

• Average the income over a 12-month period o even if the income is received during a shorter period of time, and/or o if the household receives income from additional sources.

For some self-employment households this income only represents a portion of their yearly income. In this case you would:

• Average the income over the time period it is intended to cover.

Example: If a person runs an ice cream stand each summer, but has a regular job during the rest of the year, the income from the ice cream stand can be averaged over the months that it is in operation.

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Determining Gross Monthly Self-Employment Income (Line 1 of budget worksheet):

1. Add the total amount of self-employment income (including the full amount of capital gains).

2. Subtract the cost of producing the self-employment income. 3. Divide the self-employment income by 12 or by the number of months the income

is intended to cover. 4. The resulting figure is the household’s GROSS monthly self- employment income. 5. Continue through the rest of SNAP budgeting process.

What is a Capital Gain? For SNAP purposes, a capital gain is a profit that results from the sale of capital goods, equipment, or property. This is calculated by comparing the sales price to the cost. If the sales price is greater, there is a gain. If the costs are greater, there is a loss. The cost includes, but is not limited to:

• Property • Purchase commission • Improvements, or • Sales expenses (broker's fees and commissions)

The full amount of the capital gain, if any, is counted as income for SNAP purposes.

Allowable Adjustments from Income for Self-Employment Households The allowable cost of producing the self-employment income includes, but is not limited to, the identifiable costs of:

• Labor • Stock • Raw material • Payments on the principal of the purchase price of income-producing real estate

and capital assets • Equipment and machinery • Other durable goods • Interest paid to purchase income-producing property • Insurance premiums • Taxes paid on income-producing property.

In-home child care providers can exclude:

• A standard deduction of $5.00 per day per child in care (not including their own children), or

• The amount they receive from the Child and Adult Care Food Program (CACFP) • Without documenting the specific costs of doing business, or • They can verify actual costs if they exceed the $5 standard expense

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Applicants/recipients residing in income-producing multi-unit property can exclude:

• The portion of the building expenses that are related to the cost of producing the self-employment income which includes:

o mortgage o interest o property taxes

o heating o utilities o insurance

• The portion of the building costs which are for the applicants’/recipients’ own living unit may not be excluded from the gross self-employment income, but are allowed as shelter deductions in the regular budgeting process.

Non-Allowable Adjustments for Self-Employment Households The following items are not allowable costs of producing the self-employment income:

• Net losses from previous years • Federal, state, and local income taxes • Money set aside for retirement purposes • Other work-related personal expenses (such as transportation to and from work) • Depreciation • Garnishments

To calculate a household’s monthly self-employment income, add the gross self-employment income (including capital gains) and then subtract out the cost of producing the self-employment income. The resulting figure is the household’s net monthly self-employment income. (Note: The household is still entitled to the 20% earned income deduction during the net income test.)

Net Monthly Self-Employment Income

=

Sum of gross self-employment income

–

Cost of producing self-employment income

There are special rules for self-employed farmers. See the SNAPSB Section 13, pp. 286-295 for details on countable vs. excludable income and additional allowable business costs for farmers. Military Families Figuring out what military pay and allowance must be counted as income for SNAP for families with members in the armed forces can be difficult. Here are examples of situations and how military pay and allowances are counted in SNAP budgeting: 1. When the service member lives with the rest of the family

• Count all military pay as income for SNAP purposes.

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• Count the living allowances that military personnel get in addition to their base pay. There are two allowances:

o BAS (Basic Allowance for Subsistence). This pays for meals for a military person living off-post, and for the meals for the dependents of a military person.

o BAH (Basic Allowance for Housing). This allowance replaces the older BAQ (Basic Allowance for Quarters) and the VHA (Variable Housing Allowance). The BAH is a single payment that varies by locality and is based on local costs for civilians at similar pay levels.

• Some military personnel living on-post get free housing. Free housing is an in-kind benefit that is not counted as income because the Food Stamp Act of 1977 excluded “any gain or benefit which is not in the form of money payable directly to a household…”

2. When the service member is deployed away from the family • Count only the money that is available to the family. Do not count money that the

service member keeps. • Do not count the portion of the family’s income that is hazardous duty pay.

3. When the service member’s family also receives nutrition assistance from the

Department of Defense (DoD) • The family may be eligible for both the DoD’s program and regular SNAP benefits. • Families receiving both benefits will have to count the DoD assistance as income

when computing the family’s SNAP benefit.

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KEEPING AND USING BENEFITS Using SNAP Benefits (EBT Brochure LDSS-5004; 13-INF-03; GIS 15TA/DC030) New York State uses an Electronic Benefits Transfer (EBT) system to issue SNAP benefits, TANF benefits, and Medicaid health insurance. SNAP participants use their EBT cards in the machines at checkout counters, just like debit and credit cards.

To use the SNAP benefits on the EBT card, SNAP recipients shop and take their purchases to the cash register. They swipe the card through the machine and enter their Personal Identification Number (PIN). The system will take the amount spent on food purchases out of the SNAP account. It is also possible to pay only a portion of the bill from the SNAP account and pay the remainder with cash. The machine will ask how much the participant wants to pay from their EBT SNAP account, and the participant can enter any amount up to the amount of benefits that are available in their account. The grocery store receipt will tell them how much is left. Any non-SNAP-eligible purchases can be paid for with cash. If the participant has a cash assistance account, the non-food purchases can be paid directly from the cash account by swiping the card again. Food and non-food purchases do not have to be separated at the checkout counter.

For people receiving cash assistance (TANF), some stores will give cash back from the cash account. TANF participants can also use their EBT card to get cash from Automated Teller Machines (ATMs). SNAP households can never get cash, as their SNAP benefits are only to be spent on food items at approved retailers. If the amount entered for the EBT payment is more than the amount available, the machine will reject the entire transaction. In that case, the participant should check the balance. This is done right at the cash register. Once the customer knows how much is available and enters that amount, the machine will accept the transaction, even if it is less than the amount of the purchase. The customer can then pay the balance with cash. At no point should SNAP recipients be charged a fee for using their SNAP benefits for food purchases. Unspent SNAP balances stay in the account for 365 days. The only time benefits should be expunged (removed from the account by the LDSS) earlier than 365 days is in certain NYSNIP cases, when a new NYSNIP participant has not accessed any SNAP benefits within the first 90 days of case opening—in these cases, the benefits are expunged after the first 90 days (See pg. 61 for more details about NYSNIP). SNAP participants can check their account balances at any time by calling the customer service number at 1-888-328-6399 (listed on the back of the EBT card) or by visiting https://www.mybenefits.ny.gov/ and logging into their account. Many larger stores also have machines available at the customer service desk where participants can check their balances before shopping. OTDA offers a household informational brochure (LDSS-5004) entitled Electronic Benefits Transfer (EBT) – How To Use Your Benefit Card To Get SNAP and/or Cash Benefits, which is

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provided to households as an insert with their SNAP approval notice. The brochure includes a fairly detailed section on how to prevent theft of benefits (someone improperly gaining access to your account) AND what to do if theft of benefits occurs. SNAP offices and HRA centers must provide a photo on the Common Benefit Identification Card (CBIC), or EBT card, of any Non-Temporary Assistance (NTA) SNAP head of household upon their request. Individuals who have difficulty accessing their EBT benefits, such as the homebound, can choose someone to be their authorized representative. The authorized representative should be a person that the household trusts, such as a home attendant or family member. Once appointed by the household, the authorized representative can get a separate benefit ID card and PIN, and use these to do grocery shopping for the SNAP household. SNAP recipients who have requested and used more than 4 EBT cards in a 12-month period will receive a letter from NYS. This letter is mandated by USDA under new fraud prevention rules. While NYS understands that some SNAP recipients need further information on using an EBT card, the letter does warn cardholders that misuse of EBT cards and SNAP benefits will result in a program violation that is subject to various penalties and sanctions. The letter also states that if the recipient continues to request new EBT cards they can be referred to the local SNAP Program Integrity Unit for possible investigation. Under this policy OTDA will continue to monitor EBT card requests of current SNAP recipients and their benefit redemption history going forward. Eligible Food Items SNAP benefits can be used to buy almost all foods, as well as seeds and plants that produce food for a household to eat. Households CANNOT buy the following items with SNAP benefits:

• Beer, wine, or liquor • Cigarettes or tobacco • Non-food items like toiletries, pet foods, or household supplies • Vitamins and medicines • Ready-to-eat hot foods • Prepared cold foods which will be eaten in the store (prepared cold foods to be

eaten at home are allowed) For a complete listing of SNAP eligible food items from USDA/FNS visit: http://www.fns.usda.gov/snap/eligible-food-items

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SNAP Monthly Benefits Issuance Schedule Benefits are generally made available over the first 9-14 days of every month, based on the last digit of the client’s case number. For all counties, except the 5 boroughs of NYC:

Case Number Ends In: Benefits Available On:

0 or 1 1st of the month 2 2nd of the month 3 3rd of the month 4 4th of the month 5 5th of the month 6 6th of the month 7 7th of the month 8 8th of the month 9 9th of the month

For NYC cases, benefit postings are spread out over 10 different days that are not Sundays or holidays, during the first two weeks of the month. The actual dates change from one month to the next, so NYC publishes a six-month schedule showing the exact availability dates. To view the current NYC schedule, go to: http://www.fns.usda.gov/sites/default/files/NYC_Issuance_Schedule.pdf. This schedule is based on the last digit of the case number. Find the digit in the first column of the schedule. This row lists the monthly deposit dates for benefits over the six-month period. SNAP deposits are made during the A Cycle of each month. Recertification and Reporting Requirements (SNAPSB Sections 6 and 14; 04-INF-25; 07-ADM-05; 08 ADM 09; GIS 08 TA/DC018; 11-INF-07; 13-ADM-04) A household is only authorized to be eligible for SNAP benefits for a specified, limited period of time, called the certification period. At the end of that period, the SNAP case is automatically closed unless the LDSS/case examiner enters a new certification period. The certification period can be any period up to 12 months and sometimes longer:

• Most households with income: 12-month certification period • Households with income that changes frequently: 6-month certification period • Households with no income, homebound individuals, group home residents

receiving SSI/SSD, and people that are homeless: 12-month certification period • Households where all members are a senior or disabled and with no earned

income: 24-month certification period • NYS Nutrition Improvement Project (NYSNIP) households: SSI recipients with live-

alone status who receive SNAP automatically: 48-month certification period

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Before the end of the certification period, the household will receive a notice asking them to come in for a recertification interview. If they do not come in for this interview, the case will close at the end of the certification period. At the recertification interview, the participant will be asked to bring in documentation of information that changes, such as income and housing costs. Telephone Recertification During the recertification process, existing SNAP participants will need to complete an additional interview. The purpose of the interview is the same as for new applicants, in addition to checking to make sure that no changes have occurred since the last application. SNAP offices can choose to have telephone interviews with current SNAP recipients; however, participants can always request to have the interview in person. The interview time is included with the recertification packet; however, the SNAP office may attempt to call up to four times before the interview date. If a household does not submit the recertification packet, the SNAP participant will not receive the interview. The SNAP office will not contact a household or go through with the scheduled interview if the household has not sent in their signed recertification form. It is very important that households return their completed recertification application as soon as possible. If the household sends in their recertification form, but the district cannot reach them for their interview, a “notice of missed interview” will be mailed. This notice advises the household to contact the local SNAP office immediately to reschedule their interview if they wish to have their recertification application processed. See Notice of Missed Interview on page 13 of this guide. Changes Between Certification Periods (11-INF-07; Appendix P) Besides certification periods (the specified period of time that a household is determined eligible for SNAP benefits), SNAP households must also follow complicated reporting rules. Any failure to report information when it is required may result in an overpayment, and the SNAP office will try to get the overpaid amount back, either by “recouping” it from future benefits, or through a “claims” process. This can result in the overpaid amount being taken from tax refunds. Households with Six-Month Reporting Rules The only thing these households must report during the six-month period is:

• Change in income that causes the household to be over 130% of the Federal Poverty Level. If this happens, they must report it immediately.

• ABAWDs who are subject to the ABAWD rules must also report if their work hours fall below 80 hours per month.

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Reporting Rules for Households with Certification Periods Longer than Six Months: • These households will receive a change report form to be filled out at the six-

month point of their SNAP certification. • The change report form is mailed at the end of the fifth month of certification. • The household should complete the form and return it to the LDSS in order to

continue receiving benefits. • These households must do the following under reporting rules:

o Return the 6-month reporter. o Report any change in household income above 130% of poverty, and o Report a drop in ABAWD work hours (below 80).

Households with certification periods of six months or more do not have to report any other changes in circumstances until their next SNAP recertification interview. Households that are 10 Day Reporters Some households cannot take advantage of the generous six-month reporting rules. Instead, these households are required to report almost all changes in household information within the 10th day of the month following the month of the change. Ten Day reporting households include:

• Unearned income households in which all the adults are elderly or disabled • Group home residents receiving SSI/SSD • Households with no income • Migrant workers • Homeless households • Households with a certification period of less than 4 months

Even these households do not have to report certain changes in between certification periods. For example, it is not necessary for elderly households to inform the SNAP office when their Social Security benefits increase each January, so long as the increase is less than $50 per month. It is best to check reporting rules for specifics on what must be reported by when and by which households. A helpful source of information is 04-INF-25. Case Reactivation Waiver (13-ADM-04) A new waiver now allows SNAP offices and HRA centers to reinstate SNAP benefits during the certification period for households that re-establish their eligibility. Households can do this by reporting and verifying any change in circumstances, or complying with an unfulfilled program requirement within 30 days of the date their SNAP case was closed.

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These households are not required to file a new SNAP application, or to complete an eligibility interview. A common situation where case reactivation will be used is when a household’s SNAP case has been closed for failure to submit or complete a periodic report, but the household provides the needed information after the SNAP case has been closed.

How Households Can Be Reinstated Under the Case Reactivation Waiver

Affected households must do the following within 30 days of their case closing:

1. Report and verify all changes in circumstances that have occurred 2. Provide any outstanding information that may be missing 3. Continue to be eligible for SNAP benefits, and 4. For households in Upstate Counties: The household should have at least 3 full

months remaining in their certification period following the date of fulfilling all the above requirements for reactivation. For Households in NYC: The household should have at least 4 full months remaining in their certification period following the date of fulfilling all the above requirements for reactivation.

These timeframes are necessary due to the requirements districts must follow for generating timely recertification notices and scheduling and completing recertification interviews.

OTDA reserves the right to permit exceptions to this last requirement and permit reactivation during the last 3 or 4 months of the certification period if the case circumstances merit the exception.

When the Case Reactivation Waiver Cannot Be Used Case reactivations are not re-applications for SNAP. Therefore:

• Consideration for expedited processing is not part of the reactivation process.

• Households that provide missing information or comply with eligibility requirements 30 days or more after their SNAP certification end date must file a new SNAP application.

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This waiver does not apply to households that have not complied with SNAP E&T activities resulting in their SNAP case closing:

• An individual whose SNAP case has been closed because of a SNAP E&T sanction must serve the minimum durational sanction in addition to complying with the SNAP E&T requirements as assigned by the SNAP office or HRA Center, unless the individual documents that they have become exempt from SNAP work requirements.

Emergency Food Replacement (11 GIS TA/DC018 & 21; 06 GIS TA/DC 018; 08 GIS TA/DC 031; Appendix O) SNAP has special rules to help households which experience food loss due to an emergency. SNAP recipients who experience a household misfortune which causes their food to spoil or be destroyed can receive a SNAP replacement benefit. The loss of food can be due to a situation that affects large areas, such as a storm or a flood, or can be specific to a single household, such as a fire. The amount of the replacement benefit cannot be higher than the household’s usual monthly allotment. Examples of Household Misfortune

• Extended power outage (4 hours or more) • A flood • Fire • An equipment failure (refrigerator/freezer) • Failure to pay a utility bill

Under the regular SNAP regulations, it is always possible for SNAP recipients who lose food in a “household misfortune” to obtain replacement benefits if the household:

• Reports the loss within 10 days of the misfortune either verbally (by phone or in person) or in writing to their SNAP office, AND

• Returns a signed and completed LDSS Form 2291(Appendix O) within 10 days of the date of the reported loss to the SNAP office, either by mail or in person.

Other Things to Note:

• The SNAP office should always issue replacement benefits if a household requests a replacement and has experienced a power outage/shutoff of 4 hours or longer.

• SNAP offices are advised not to require the household to bring in spoiled food as verification of need, as this is inappropriate for reasons of both health and administrative impracticality.

• A household may not be denied replacement SNAP benefits if it has applied for replacement issuances in the past.

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• The SNAP office may use available information to confirm or deny the accuracy of the statement attesting to the household misfortune.

Disaster SNAP (USDA D-SNAP Guide) In the event of a large-scale disaster, states may request permission from USDA to operate a Disaster SNAP program (D-SNAP). The D-SNAP program has special income rules and a very simple application process. It provides benefits quickly to households which would not ordinarily qualify for SNAP benefits, but which suddenly need food assistance due to the disaster situation. D-SNAP may also include special provisions for existing recipients. The largest D-SNAP to date was implemented after Hurricane Katrina. New York State has operated D-SNAP programs in the following counties since 2001:

• Fall of 2001 – in New York City, after the World Trade Center attacks • Summer of 2006 – in 12 upstate counties, in response to severe flooding • Summer of 2011 – in 16 upstate counties, in response to Hurricane Irene and

Tropical Storm Lee • Fall of 2012 – in Westchester County and in 10 full and 2 partial zip codes in NYC, in

response to Super Storm Sandy For more detailed information about Disaster SNAP benefits, consult “An Advocate’s Guide to the Disaster Food Stamp Program,” issued by the Food Research and Action Center (FRAC). This document can be found here: http://frac.org/wp-content/uploads/2009/09/dfspguide06.pdf. Transitional Benefits (02 ADM-07; 09-ADM-22) Most households who leave TANF are now automatically eligible for transitional SNAP benefits. New York’s transitional SNAP is called the Transitional Benefits Alternative (TBA). TBA was implemented to provide a critical work support to newly employed households. However, TBA is available to other households who leave TANF, so long as the reason for the case closing does not involve a SNAP violation. New York does not provide TBA benefits to households who miss their TANF/SNAP recertification interview. At the time the TANF case is closed, if a household is eligible for TBA, the caseworker will authorize TBA for 5 months – even if a household had less than 5 months left in its SNAP certification period. The TBA benefit is frozen at the SNAP benefit level issued prior to the Family Assistance case closing, but the Family Assistance is no longer counted as income. There is no income “cap” for TBA; even households with gross incomes above 130% of poverty are eligible. The household is not obligated to report any change in income, resources, or household composition during the TBA period. Before the TBA period expires, households are sent a

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recertification notice to allow them to certify for ongoing SNAP benefits. To “unfreeze” the SNAP benefits during the 5-month TBA period – for example, if a household’s income dramatically decreases or a new member joins the household – the household would have to undergo an early recertification. Temporary assistance households without children who leave Safety Net Assistance (SNA) cannot get TBA benefits, but they may be eligible for regular SNAP benefits. SNAP households (with children) who leave TANF or SNA are eligible for TBA. For more information on this policy change see 09-ADM-22. New York State Nutrition Improvement Project – NYSNIP (04 LCM-13; GIS 12TA/DC019; GIS 13 TA/DC030) In recent years, USDA has encouraged states to develop combined application projects (CAPs) to make it easier for elderly and disabled recipients of Supplemental Security Income (SSI) to receive SNAP. OTDA operates a CAP called the New York State Nutrition Improvement Project (NYSNIP), which automatically enrolls single SSI live-alone recipients into SNAP. No separate SNAP application, no interview, and no separate verification are needed. Who can participate? NYSNIP is available only to SSI live-alone recipients – those classified as “living alone” by SSA (i.e. - live by themselves and pay their own food, shelter, and clothing expenses). This code, called an “A/A,” designates a federal SSI living code of ‘A’ and a State Supplement code of ‘A.’ SSA sets these codes, not the SNAP office/HRA center. Only SSA can code SSI recipients as live-alones. The SNAP office/HRA center uses data matching to find eligible NYSNIP participants each month from the list of newly approved SSI recipients in NYS. SSI couples and recipients in other living arrangement categories cannot participate in NYSNIP, but they can receive SNAP through the regular application process. SSI live-alone applicants will not get SNAP benefits through NYSNIP; only if/when they become SSI recipients will their NYSNIP benefits start. Unlike Medicaid or SSI, there is no retroactive NYSNIP eligibility. NYSNIP benefits start the first or second month after the first ongoing SSI check is issued.

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NYSNIP eligibility rules for 18- to 21-year-old SSI recipients coded A/A by SSA: SSI participants age 18-21 who live with their parents can be coded (A/A) designating them as an SSI live-alone. This is true even if they reside with their parents, as long as they are paying their parents for living at home. These SSI recipients:

• Can participate in NYSNIP as a separate SNAP household even if they live with their parent(s), as long as the parents are not in receipt of SNAP benefits.

• If both the parents and the 18-21 year-old SSI live-alone are either current SNAP participants or are applying for SNAP, then this family must apply together as one household under regular non-NYSNIP SNAP eligibility rules.

NYSNIP eligibility rules for adult SSI recipients coded A/A by SSA who are living with their 18- to 21-year-old children: SSI participants who live with their 18- to 21-year-old children can be coded (A/A) designating them as an SSI live alone. These SSI recipients:

• Can participate in NYSNIP as a separate SNAP household even if they live with their children who are ages 18-21,

• As long as the 18- to 21-year-old child(ren) is not applying or currently receiving SNAP benefits.

• If both the adult SSI recipient and their children ages 18-21 are either participating in or apply for SNAP, then this family must apply together as one household under regular non-NYSNIP SNAP eligibility rules.

What are the benefit amounts and certification periods? NYSNIP has standardized SNAP benefits; the SNAP budget is not individualized. The benefit standards consider four factors: cost of shelter, eligibility for the heating/cooling standard utility allowance, presence of other income, and geographic location. A chart listing the NYSNIP benefit allotments can be found at HungerSolutionsNY.org in the News and Resources section. One of the guiding principles behind NYSNIP is that participants should get the same or more SNAP benefits than they would ordinarily receive through the regular SNAP application process. Anyone who would receive a lower amount should be able to “opt out” of NYSNIP and enter the regular SNAP application process if they wish. Some SNAP recipients will be eligible for a higher SNAP allotment if they opt out of NYSNIP. This is because those households with high shelter costs (more than$246) who did not receive a HEAP benefit of $21 and are not paying for heating/cooling costs will be receiving a minimum benefit of $26 or $17 through NYSNIP. Actual shelter costs may exceed $246 in the regular SNAP budgeting process and because NYSNIP is a standardized benefit, the costs are not budgeted in the same way. It is important to verify whether NYSNIP is the most advantageous way for households to access SNAP benefits. New SNAP recipients under NYSNIP will initially receive the minimum benefit level of $16. However, by filling out and returning a short form (LDSS-4841) included with their NYSNIP opening notice (includes questions about shelter and utility costs), benefits may be adjusted up to the maximum SNAP benefit level – as high as $194.

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New NYSNIP participants must access their SNAP account within 90 days of the case opening. If redemption of SNAP benefits does not occur within 60 days, OTDA sends a reminder notice urging the individual to use their SNAP benefits within the next month. The reminder has a list of community agencies that NYSNIP recipients can call for assistance. At the end of the 90 days, if the person still has not accessed any SNAP benefits, OTDA closes the NYSNIP case. This individual has to go through the regular SNAP application process if s/he wants to rejoin NYSNIP or to participate in the regular SNAP application process. The certification period under NYSNIP lasts up to 4 years, with a short mail-in questionnaire required at the midway point. Recipients MUST return this questionnaire – called an “interim report” (LDSS-4836) – in order to continue receiving SNAP for the remaining 2-year period. Participants who lose SSI live-alone status will be taken out of NYSNIP; however, they can still receive regular SNAP benefits, if eligible. NYSNIP benefit allotments will change on October 1, 2015. NYSNIP recipients who do not pay separately for heating or cooling costs and have not received a HEAP benefit of $21 or more in the last twelve months or in the current month will receive a shelter code type 96 or 97 (no SUA) and will see their SNAP benefit decrease substantially. This is a result of the federal changes to the farm bill. Budgets may need to be looked at closely to see if the person would benefit from using regular SNAP rules or if NYSNIP enrollment is more beneficial. Some households may receive a higher benefit amount by switching to the regular SNAP program because their actual shelter costs are higher than the capped amount of $246 allowed in the NYSNIP matrix. Medical bills are also not counted in the NYSNIP matrix. NYSNIP recipients who see a decrease in their SNAP benefits can ask the SNAP office to do a comparison budget to help them determine whether they will receive a higher SNAP benefit by using regular SNAP rules or if NYSNIP enrollment is more beneficial. The SNAP office should then give these NYSNIP recipients the opportunity to opt out of NYSNIP. If a person decides to opt out of NYSNIP, they will no longer be eligible for the 48-month certification period. A new application does not need to be submitted for people that transition from NYSNIP to the regular SNAP program. New SSI live-alone recipients not already in receipt of SNAP are placed into NYSNIP at the minimum benefit level. Included with their opening notice is the shelter questionnaire (the “NYSNIP Food Stamp Case Information Collection Sheet” (LDSS-4841)). Once the local SNAP office receives the person’s completed shelter questionnaire, the SNAP benefits can be adjusted to take into account the person’s shelter and utility expenses. Any new NYSNIP participant who fails to access their SNAP account within 60 days will get the reminder notice mentioned above, and have an additional 30 days to access their benefits. The NYSNIP notices contain a lot of information which may be overwhelming to many SSI recipients. Community agencies and advocacy groups working with the elderly and disabled can help new NYSNIP participants understand what the program is all about, assist in completing the shelter & utility questionnaire, and encourage people to use their

63

SNAP benefits. Ongoing recipients may need help completing the interim mailer and returning it to their local SNAP office.

NYSNIP BENEFITS MATRIX BY SHELTER TYPES

10/01/15 - 09/30/16

High shelter = More than $246/month Low shelter = Less than or equal to $246/month SUA = Eligible for Level 1 (heating/cooling) SUA *SUA/$21 HEAP = Eligible for Level 1 (heating/cooling) SUA **No SUA = Not eligible for Level 1 (heating/cooling) SUA No Shelter/ SUA = no information on households shelter costs or heating/cooling expenses For more information on changes to the NYSNIP program and for any updates to the current NYSNIP benefit matrix, see the News and Resources section at HungerSolutionsNY.org.

HOUSEHOLD MONTHLY FOOD STAMP BENEFIT AMOUNT New York City Nassau/Suffolk Upstate

Shelter Type 94 (High Shelter/SUA)

SSI Only Other Income

$194 $194

$194 $194

$194 $194

Shelter Type 95 (Low Shelter/SUA)

SSI Only Other Income

$194 $189

$183 $174

$159 $150

Shelter Type 96 (High Shelter/ SUA/$21 HEAP)

SSI Only Other Income

$194 $194

$194 $194

$194 $194

Shelter Type 96 (High Shelter/No SUA)

SSI Only Other Income

$26 $17

$26 $17

$26 $17

Shelter Type 97 (Low Shelter/ SUA/$21 HEAP)

SSI Only Other Income

$194 $189

$183 $174

$159 $150

Shelter Type 97 (Low Shelter/No SUA)

SSI Only Other Income

$16 $16

$16 $16

$16 $16

Shelter Type 98 (No Shelter or SUA Data)

SSI Only Other Income

$16 $16

$16 $16

$16 $16

Appendix A –

Common Acronyms

COMMON ACRONYMS

ABAWDs Able-Bodied Adults Without Dependents (may be subject

to time-limited SNAP benefits) ADM Administrative Directive (issued by OTDA to notify LDSS

about policy and procedures which must be followed in the administration of programs)

Cat el Categorical Eligibility DSS also LDSS Department of Social Services

Local Department of Social Services (the county-level SNAP administering agency)

EBT Electronic Benefits Transfer (a system of disbursing

temporary assistance and SNAP benefits to households using a swipe card)

E&T Employment and Training Program FA Family Assistance (the name for New York State’s TANF

program, which provides temporary assistance to families with children)

FNS Food and Nutrition Service (the division of USDA

responsible for administering SNAP and child nutrition programs)

GIS General Information System Messages (issued by OTDA to

provide immediate direction about current OTDA program policy and procedures to LDSS offices)

Household Under SNAP rules Household is defined as people who live

together and purchase and prepare meals together. HRA Human Resources Administration (the name for New York

City’s Department of Social Services) INF Informational Letter (issued by OTDA includes articles of

general interest to LDSS staff including pamphlets or brochures, new or revised lists of contacts, etc.)

INS Immigration and Naturalization Service (federal

immigration agency now called USCIS – United States Citizenship and Immigration Services)

IPV Intentional Program Violation (disqualification imposed

on someone who has committed fraud)

LDSS Local Department of Social Services (the county- level SNAP administering agency)

LPR Lawful (or Legal) Permanent Resident (also known as “green card” holder)

MA Medicaid MARU Mail-In Application Referral Unit- (HRA initiative that

encourages households to apply for SNAP through mail or fax) NTA/NPA Non-Temporary Assistance/Non-Public Assistance (household in which no one receives temporary assistance) NOMI Notice of Missed Interview NYSNIP New York State Nutrition Improvement Project (program which provides automatic SNAP benefits to SSI

live-alone recipients) OTDA also NYSOTDA Office of Temporary and Disability Assistance (the state

agency responsible for administering SNAP in New York State)

SN or SNA Safety Net Assistance (the state’s temporary assistance

program for households without children and households who have exceeded the 5 year TANF time limit)

SNAP Supplemental Nutrition Assistance Program (the new

name for the Food Stamp Program) SNAPSB Supplemental Nutrition Assistance Program Source Book

(New York State administrative policy manual) SSA Social Security Administration SSD or SSDIB Social Security Disability Insurance Benefits SSI Supplemental Security Income (cash assistance program

for low-income elderly [65+] and disabled individuals – is administered by SSA)

SSN Social Security Number SUA Standard Utility Allowance TA Temporary Assistance (generic term for SNA and TANF --

also known as “cash assistance,” “public assistance” or “welfare”)

TANF Temporary Assistance for Needy Families (the temporary assistance program for families with children, also known in New York State as Family Assistance)

TBA Transitional Benefits Alternative (the name for New York State’s transitional SNAP for people leaving TANF) UIB Unemployment Insurance Benefits USCIS United States Citizenship and Immigration Services (the

federal immigration agency formerly known as INS – Immigration and Naturalization Service)

USDA United States Department of Agriculture (administers

SNAP on the federal level) WFSNAPI Working Families Supplemental Nutrition Assistance

Program Initiative (simplifies application process for working families who qualify)

Appendix B –

SNAP Organizational Chart

Prep

ared

by

Hu

nge

r Sol

uti

ons

New

Yor

k U

pdat

ed S

epte

mbe

r 201

5

Org

aniz

atio

nal

Str

uct

ure

of

the

Sup

ple

men

tal N

utr

itio

n A

ssis

tan

ce P

rogr

am

Un

ited

Sta

tes

Dep

artm

ent

of

Ag

ricu

ltu

re

(USD

A)

Fede

ral a

gen

cy re

spon

sibl

e fo

r adm

inis

trat

ion

of t

he S

upp

lem

enta

l Nu

trit

ion

Ass

ista

nce

Pro

gram

(SN

AP)

.

Issu

es S

NA

P re

gula

tion

s an

d po

licie

s. M

onit

ors

stat

e ag

ency

per

form

ance

.

Off

ice

of

Tem

po

rary

an

d D

isab

ilit

y A

ssis

tan

ce (

OTD

A)

Resp

onsi

ble

for a

dmin

iste

ring

SN

AP,

the

new

nam

e fo

r th

e Fo

od S

tam

p Pr

ogra

m (F

SP) i

n N

ew Y

ork

Stat

e.

Is

sues

sta

te re

gula

tion

s, p

olic

y di

rect

ives

and

tra

ins

and

mon

itor

s Lo

cal D

epar

tmen

ts o

f Soc

ial S

ervi

ces.

Resp

onsi

ble

for a

dmin

istr

atio

n o

f sta

te S

NA

P Em

ploy

men

t &

Tra

inin

g Pl

an a

nd

ABA

WD

pol

icie

s.

Loca

l Dep

artm

ent

of S

ocia

l Ser

vice

s (L

DSS

) or

Hu

man

Res

ourc

e A

dm

inis

trat

ion

(H

RA

) In

NYC

Cou

nty

gov

ernm

ent a

gen

cy d

eter

min

es S

NA

P el

igib

ility

an

d is

sues

ben

efit

s to

elig

ible

h

ouse

hol

ds.

H

ouse

hold

s ap

ply

for S

NA

P th

rou

gh t

hei

r LD

SS/H

RA.

Un

ited

Sta

tes

Co

ng

ress

Con

gres

s au

thor

izes

th

e Su

pple

men

tal N

utr

itio

n A

ssis

tan

ce P

rogr

am th

roug

h th

e Fa

rm B

ill e

very

five

yea

rs

Appendix C –

“How To” Sheet for ordering SNAP application and

OTDA Form 876 EL

Prepared by Hunger Solutions New York SNAP Prescreening Guide September 2015

ORDERING BLANK SNAP APPLICATIONS FROM OTDA

Hard copies of SNAP applications and other related publications from OTDA are available free of charge. To order copies of these documents in large quantities follow the following steps.

Order OTDA Publications:

To order OTDA Publications, visit http://otda.ny.gov/programs/publications/order/ or fill out OTDA Form 876 and mail the completed form to the below address. Please allow 3 weeks for processing of order. Form 867 can be found on the next page of this guide. NYS Office of Temporary and Disability Assistance Document Services PO Box 1990 Albany, NY 12201 Fax: 518-402-0084 Email: Forms.Orders@otda.ny.gov This information can be found at http://otda.ny.gov/programs/publications/order/

1. Instructions for filling out the form: For SNAP only applications use document number 4826 For Document Title: use “SNAP Benefits

Application/Recertification” Make sure to specify language(s) you would like:

• English • Spanish • Arabic • Chinese

• Haitian-Creole • Korean • Russian

2. Things to know about ordering applications:

Request for the same items are limited to twice per year Remember to order a sufficient supply at least two months in

advance.

OTDA-876 (Rev. 7/09) REQUEST FOR FORMS OR PUBLICATIONS

Submit Request To: NYS Office of Temporary and Disability Assistance Document Services P.O. Box 1990 Albany, N.Y. 12201

Deliver Supply To: (Complete Address)

We recommend that you establish a re-order point to insure sufficient quantities are on hand to meet your needs. Please order documents in numerical sequence and allow 3 weeks for processing

and shipping of your order. FORM NUMBER FORM TITLE QUANTITY

REQUESTEDQUANTITY SHIPPED

Agency Submitting Request:

Name of Person Submitting Request:

Phone Number

Date Submitted

E-mail Address: Shaded areas to be completed by Document Services staff Cost Center Code Date Filled Filled By

Sent VIA: UPS Truck Other

Appendix D –

SNAP APPLICATION

FORM and “How to Complete” Booklet

(LDSS-4826; LDSS-4826A)

LDSS

-482

6A (R

ev. 8

/12)

N

EW Y

OR

K ST

ATE

OFF

ICE

OF

TEM

POR

ARY

AND

DIS

ABIL

ITY

ASS

ISTA

NC

E

HO

W T

O C

OM

PLET

E TH

E SU

PPLE

MEN

TAL

NU

TRIT

ION

ASS

ISTA

NC

E PR

OG

RAM

(SN

AP)

A

PPLI

CA

TIO

N/R

ECER

TIFI

CA

TIO

N A

ND

APP

LIC

AN

T/R

ECIP

IEN

T R

IGH

TS A

ND

RES

PON

SIB

ILIT

IES

FOR

SN

AP

SN

AP

is

th

e n

ew

nam

e f

or

the F

oo

d S

tam

p P

rog

ram

Use

Th

is F

orm

If

Ap

ply

ing

Fo

r S

NA

P O

nly

If yo

u ar

e on

ly a

pply

ing

for

SNAP

you

can

use

this

sho

rter

appl

icat

ion.

If y

ou w

ould

like

to a

pply

for

othe

r be

nefit

s su

ch a

s Te

mpo

rary

Ass

ista

nce,

C

hild

Car

e A

ssis

tanc

e, H

ome

Ener

gy A

ssis

tanc

e or

Med

icai

d pl

ease

ask

for a

diff

eren

t app

licat

ion.

T

his

app

lica

tion

ca

n o

nly

be u

sed t

o a

pp

ly f

or

SN

AP

Be

ne

fits

.

Wh

en

Yo

u A

re A

pp

lyin

g F

or

SN

AP

Yo

u ca

n fil

e an

app

licat

ion

the

sam

e da

y yo

u re

ceiv

e it.

If y

ou a

re e

ligib

le, b

enef

its w

ill be

pro

vide

d ba

ck to

the

filin

g da

te o

f you

r app

licat

ion.

You

can

file

your

app

licat

ion

befo

re y

ou h

ave

an in

terv

iew

.

We

mus

t acc

ept y

our a

pplic

atio

n if,

at a

min

imum

, it c

onta

ins

your

nam

e, a

ddre

ss (i

f you

hav

e on

e), a

nd a

sig

natu

re. T

his

info

rmat

ion

will

esta

blis

h yo

ur a

pplic

atio

n fil

ing

date

. How

ever

, the

app

licat

ion

proc

ess

incl

udin

g th

e in

terv

iew

and

a s

igna

ture

on

page

5 o

f the

app

licat

ion/

rece

rtific

atio

n m

ust b

e co

mpl

eted

for u

s to

det

erm

ine

your

elig

ibilit

y.

Yo

u ca

n ap

ply

for

and

get

SNAP

for

elig

ible

hou

seho

ld m

embe

r(s)

eve

n if

you

or s

ome

othe

r m

embe

rs o

f yo

ur h

ouse

hold

are

not

elig

ible

for

be

nefit

s be

caus

e of

imm

igra

tion

stat

us. F

or e

xam

ple,

inel

igib

le a

lien

pare

nts

can

appl

y fo

r SN

AP fo

r th

eir

child

ren

and

rece

ive

bene

fits

for

thei

r el

igib

le c

hild

ren.

You

can

still

appl

y an

d be

elig

ible

for S

NAP

eve

n if

you

have

reac

hed

your

Tem

pora

ry A

ssis

tanc

e tim

e lim

its.

Ne

ed

SN

AP

Ben

efi

ts R

igh

t A

wa

y?

Yo

u M

ay

Be

Eli

gib

le F

or

Ex

ped

ited

Pro

ce

ss

ing

Of

Yo

ur

SN

AP

Ap

pli

ca

tio

n.

If yo

ur h

ouse

hold

has

littl

e or

no

inco

me

or li

quid

res

ourc

es, o

r if

your

ren

t and

util

ity e

xpen

ses

are

mor

e th

an y

our

inco

me

and

liqui

d re

sour

ces,

or

you

are

a m

igra

nt o

r sea

sona

l far

m w

orke

r with

littl

e or

no

inco

me

or re

sour

ces

whe

n yo

u ap

ply,

you

may

be

qual

ified

to re

ceiv

e SN

AP b

enef

its w

ithin

5

cale

ndar

day

s af

ter t

he d

ate

that

you

app

ly. Y

our w

orke

r will

alw

ays

revi

ew y

our c

ircum

stan

ces

to s

ee if

you

are

qua

lifie

d fo

r exp

edite

d pr

oces

sing

of

you

r SN

AP a

pplic

atio

n. A

pro

cess

is in

pla

ce to

issu

e SN

AP b

enef

its to

all

elig

ible

hou

seho

lds

who

mee

t the

sta

ndar

ds fo

r exp

edite

d se

rvic

e.

Wh

ere

Yo

u C

an

Ap

ply

Fo

r S

NA

P B

en

efi

ts

If yo

u liv

e ou

tsid

e of

New

Yor

k C

ity, c

all o

r vis

it th

e so

cial

ser

vice

s di

stric

t in

the

coun

ty w

here

you

live

and

ask

for a

n ap

plic

atio

n pa

ckag

e. Y

ou c

an

get t

he a

ddre

ss a

nd p

hone

num

ber b

y ca

lling

toll

free

l-800

-342

-300

9, o

r app

ly o

n-lin

e at

myB

enef

its.n

y.go

v.

If yo

u liv

e in

New

Yor

k C

ity a

nd y

ou a

re n

ot a

lso

appl

ying

for T

empo

rary

Ass

ista

nce,

cal

l or v

isit

any

SNA

P O

ffice

and

ask

for a

n ap

plic

atio

n pa

ckag

e.

You

can

get t

he a

ddre

ss a

nd p

hone

num

ber b

y ca

lling

1-71

8-55

7-13

99 o

r tol

l fre

e l-8

00-3

42-3

009,

or a

pply

on-

line

at m

yBen

efits

.ny.

gov.

H

av

ing

Pro

ble

ms

Co

min

g T

o U

s F

or

A S

NA

P A

pp

oin

tmen

t?

If it

is d

iffic

ult f

or y

ou to

com

e in

for

a SN

AP a

pplic

atio

n ap

poin

tmen

t (re

ason

s m

ay in

clud

e em

ploy

men

t, he

alth

issu

es, t

rans

porta

tion

or c

hild

car

e pr

oble

ms)

, you

may

hav

e so

meo

ne e

lse

appl

y fo

r you

, or y

ou m

ay a

pply

on-

line

at m

yBen

efits

.ny.

gov.

You

als

o ca

n m

ail u

s yo

ur a

pplic

atio

n or

dro

p it

off a

nd, i

n so

me

circ

umst

ance

s; w

e ca

n in

terv

iew

you

by

tele

phon

e.

Plea

se c

onta

ct th

e so

cial

ser

vice

s di

stric

t if y

ou h

ave

any

ques

tions

, to

see

if yo

u ar

e el

igib

le fo

r a te

leph

one

inte

rvie

w, o

r if

yo

u n

ee

d t

o r

es

ch

ed

ule

a

n i

nte

rvie

w.

LDSS

-482

6A (R

ev. 8

/12)

P

age

2

INST

RU

CTI

ON

S O

N H

OW

TO

CO

MPL

ETE

THE

SNA

P A

PPLI

CA

TIO

N/R

ECER

TIFI

CA

TIO

N

Ple

ase

PRIN

T cl

early

in b

lue

or b

lack

ink.

D

o N

OT

prin

t in

the

shad

ed a

reas

. B

e su

re to

com

plet

e ea

ch s

ectio

n.

If y

ou

are

ap

ply

ing a

s s

om

eo

ne

’s r

ep

resen

tative

, p

lea

se

print

info

rma

tio

n a

bou

t th

at p

ers

on,

no

t yo

urs

elf.

SEC

TIO

N 1

: APP

LIC

AN

T IN

FOR

MA

TIO

N

NA

ME:

PR

INT

your

lega

l nam

e in

clud

ing

your

firs

t nam

e, m

iddl

e in

itial

and

last

nam

e.

TELE

PHO

NE

NU

MB

ER: P

RIN

T yo

ur h

ome

phon

e nu

mbe

r. O

THER

PH

ON

E: P

RIN

T an

othe

r pho

ne n

umbe

r whe

re y

ou c

an b

e re

ache

d, if

you

hav

e on

e.

RES

IDEN

CE

AD

DR

ESS:

PR

INT

the

stre

et, a

venu

e, ro

ad, e

tc.,

whe

re y

ou n

ow li

ve. P

RIN

T th

e ci

ty y

ou li

ve in

. PR

INT

your

zip

cod

e.

MAI

LIN

G A

DD

RES

S: P

RIN

T yo

ur m

ailin

g ad

dres

s if

it is

diff

eren

t fro

m y

our r

esid

ence

. O

THER

NA

ME:

PR

INT

any

mai

den

nam

es, n

ames

from

a p

revi

ous

mar

riage

, or o

ther

nam

es th

at a

ny p

erso

n lis

ted

has

or n

ow u

ses.

C

heck

() w

heth

er y

ou a

re a

pply

ing

or re

certi

fyin

g fo

r SN

AP

. C

heck

() i

f you

wis

h to

rece

ive

notic

es in

Spa

nish

and

Eng

lish

or ju

st E

nglis

h.

SEC

TIO

N 2

: S

ign

your

nam

e an

d da

te, O

NLY

if y

ou w

ant t

o su

bmit

your

app

licat

ion

with

out c

ompl

etin

g th

e ne

xt p

age

at th

is ti

me.

You

mus

t co

mpl

ete

the

appl

icat

ion

and

sign

on

page

5 fo

r us

to d

eter

min

e yo

ur e

ligib

ility.

SE

CTI

ON

3: H

OU

SEH

OLD

MEM

BER

S IN

FOR

MA

TIO

N:

LIST

TH

E N

AM

ES O

F EV

ERYO

NE

WH

O L

IVES

WIT

H Y

OU

, EVE

N IF

TH

EY A

RE

NO

T A

PPLY

ING

WIT

H Y

OU

. PR

INT

your

full

nam

e fir

st. T

hen

PRIN

T th

e na

mes

of t

he o

ther

peo

ple

who

live

with

you

: PR

INT

the

da

te o

f b

irth

, S

ocia

l S

ecu

rity

Num

be

r (if

the

ind

ivid

ua

l d

oe

s n

ot

ha

ve

a S

SN

, ente

r “n

on

e”)

, m

arita

l sta

tus a

nd

se

x f

or

eac

h pe

rson

ap

plyi

ng.

Che

ck (

) Yes

or N

o to

tell

us w

ho is

app

lyin

g.

For e

ach

pers

on in

the

hous

ehol

d, P

RIN

T ho

w th

ey a

re re

late

d to

you

(for

exa

mpl

e: w

ife, s

on, f

riend

, etc

.).

Che

ck (

) Yes

if th

at p

erso

n bu

ys a

nd/o

r pre

pare

s fo

od w

ith y

ou.

Che

ck (

) Yes

or N

o to

indi

cate

if e

ach

pers

on a

pply

ing

is H

ispa

nic

or L

atin

o.

Ent

er Y

(Yes

) or N

(No)

for e

ach

race

*.

Rac

e/E

thni

c co

des:

I – N

ativ

e A

mer

ican

or A

lask

an N

ativ

e, A

– A

sian

, B –

Bla

ck o

r Afri

can

Am

eric

an, P

– N

ativ

e H

awai

ian

or P

acifi

c Is

land

er,

W –

Whi

te

U –

Unk

now

n (M

A O

NL

Y)

*The

se a

nsw

ers

are

optio

nal b

ut, i

f not

com

plet

ed, t

he in

terv

iew

er m

ay h

ave

to r

ecor

d th

em b

y ob

serv

atio

n. T

his

info

rmat

ion

will

not a

ffect

yo

ur e

ligib

ility

.

LDSS

-482

6A (R

ev. 8

/12)

P

age

3

SEC

TIO

N 4

: Ans

wer

all

ques

tions

in s

ectio

n 4.

Fill

in n

ames

of i

ndiv

idua

ls w

ho a

re n

ot U

.S. c

itize

ns.

SEC

TIO

N 5

: IN

CO

ME:

Lis

t all

your

inco

me

and

the

inco

me

of e

very

one

livin

g w

ith y

ou. P

RIN

T th

e na

me

of th

e pe

rson

rece

ivin

g th

e in

com

e,

the

sour

ce o

f inc

ome

and

how

ofte

n it

is re

ceiv

ed. I

ncom

e ca

n in

clud

e: R

egul

ar jo

b (w

ages

), in

com

e be

fore

stri

ke, o

n-th

e-jo

b-tra

inin

g, m

ilitar

y re

serv

es,

natio

nal g

uard

, w

ork

stud

y, a

limon

y, c

hild

sup

port,

edu

catio

nal a

ssis

tanc

e (g

rant

s, s

chol

arsh

ips,

etc

.), f

riend

s or

rel

ativ

es (

othe

r th

an lo

ans)

, tem

pora

ry a

ssis

tanc

e, p

ensi

ons

or r

etire

men

t, S

uppl

emen

tal S

ecur

ity In

com

e (S

SI),

Soc

ial S

ecur

ity b

enef

its, v

eter

ans

bene

fits,

u

nem

plo

ym

en

t b

enefits

, w

ork

er’s c

om

pen

sa

tio

n,

ba

bysittin

g,

taxi d

rivin

g,

cle

an

ing h

om

es o

r o

the

r b

uild

ings,

farm

ing/r

an

ch

ing, i

ncom

e fro

m a

ro

omer

, inc

ome

from

a b

oard

er o

r arts

and

cra

fts.

NO

TE

: Fos

ter C

are

Pay

men

ts a

nd S

NA

P –

You

may

cho

ose

to in

clud

e th

e fo

ster

car

e ch

ild o

r adu

lt in

the

SN

AP

hou

seho

ld. I

f you

do,

any

as

soci

ated

fost

er c

are

paym

ents

will

be c

ount

ed a

s in

com

e. A

ll ot

her i

ncom

e or

reso

urce

s of

the

fost

er c

are

child

als

o w

ill be

cou

nted

. If

you

have

any

que

stio

ns a

bout

this

, mak

e su

re to

ask

you

r wor

ker.

Be

sure

to a

nsw

er a

ll ot

her q

uest

ions

in s

ectio

n 5.

SE

CTI

ON

6:

RES

OU

RC

ES:

Res

ourc

es d

o no

t af

fect

the

elig

ibilit

y of

mos

t ho

useh

olds

app

lyin

g fo

r S

NA

P. H

owev

er,

som

e re

sour

ce

info

rmat

ion

is u

sed

to d

eter

min

e if

you

qual

ify fo

r exp

edite

d pr

oces

sing

of y

our a

pplic

atio

n.

Ans

wer

all

the

ques

tions

in S

ectio

n 6

for y

ours

elf a

nd e

very

one

who

is a

pply

ing

for S

NA

P. L

ist t

he d

olla

r ($)

am

ount

or v

alue

and

the

nam

e of

th

e pe

rson

who

has

the

reso

urce

. Be

sure

to li

st a

ny jo

int h

oldi

ngs.

Res

ourc

es m

ay in

clud

e an

y of

the

follo

win

g: c

ash

on h

and,

cas

h he

ld

by o

ther

s, c

heck

ing

or s

avin

gs a

ccou

nt,

savi

ngs

bond

s, i

ndiv

idua

l re

tirem

ent

acco

unt,

pens

ion

plan

, in

divi

dual

dev

elop

men

t ac

coun

t, st

ocks

/bon

ds, m

utua

l fun

ds, t

rust

fund

, mon

ey m

arke

t cer

tific

ates

, bui

ldin

gs, l

and,

rent

al p

rope

rty, v

acat

ion

or re

crea

tiona

l pro

perty

or h

ouse

ot

her t

han

hom

e.

SEC

TIO

N 7

: LIV

ING

AR

RA

NG

EMEN

TS A

ND

EXP

ENSE

S:

PR

INT

the

amou

nt y

ou p

ay fo

r re

nt, m

ortg

age,

roo

m a

nd b

oard

or

othe

r ho

usin

g. L

ist t

he d

olla

r ($

) am

ount

that

you

pay

for

your

pro

perty

ta

xe

s a

nd h

om

eo

wn

er’s in

su

ran

ce

(in

clu

din

g fire

in

su

ran

ce

).

If yo

u pa

y fo

r you

r hea

t sep

arat

ely,

che

ck (

) wha

t typ

e of

hea

t you

hav

e.

A

lso,

indi

cate

if:

yo

u pa

y fo

r ot

her

utilit

ies

sepa

rate

ly fr

om y

our

rent

/mor

tgag

e, h

ave

tele

phon

e co

sts

or a

ir co

nditi

onin

g co

sts

and

if yo

u do

, w

ho p

ays

the

sepa

rate

exp

ense

?

anyo

ne p

ays

cour

t-ord

ered

chi

ld s

uppo

rt an

d if

so, w

ho, h

ow m

uch

and

the

frequ

ency

of p

aym

ents

?

anyo

ne a

pply

ing

has

any

med

ical

bills

suc

h as

in-h

ome

nurs

ing

serv

ice,

den

ture

s, h

earin

g ai

d, e

yegl

asse

s, s

eein

g ey

e do

g or

ser

vice

an

imal

, he

alth

insu

ranc

e an

d m

edic

al p

aym

ents

, ho

spita

l or

nurs

ing

care

, m

edic

al o

r de

ntal

ser

vice

s, p

resc

riptio

n dr

ugs

or m

edic

al

trans

porta

tion?

anyo

ne in

you

r hou

seho

ld is

on

Med

icai

d, w

ith a

spe

ndow

n an

d if

so, w

ho a

nd h

ow m

uch?

anyo

ne in

you

r hou

seho

ld is

enr

olle

d in

sch

ool o

r in

a tra

inin

g pr

ogra

m a

nd if

so,

who

and

whe

re?

Be

sure

to a

nsw

er a

ll ot

her q

uest

ions

in s

ectio

n 7.

LDSS

-482

6A (R

ev. 8

/12)

P

age

4

SEC

TIO

N 8

: LEG

AL S

TATE

MEN

TS:

Rea

d th

is s

ectio

n ca

refu

lly o

r hav

e so

meo

ne re

ad it

to y

ou.

For

Life

line,

SN

AP a

pplic

ants

/reci

pien

ts m

ust

chec

k (

) th

e bo

x if

you

do

no

t au

thor

ize

the

NYS

Offi

ce o

f Te

mpo

rary

and

Dis

abilit

y A

ssis

tanc

e to

pos

sibl

y di

sclo

se y

our n

ame

and

addr

ess

to y

our

tele

phon

e se

rvic

e pr

ovid

er. Y

our

tele

phon

e se

rvic

e pr

ovid

er m

ay o

r m

ay

not u

se th

is in

form

atio

n to

enr

oll y

ou in

thei

r Life

line

Ser

vice

for a

dis

coun

ted

tele

phon

e ra

te. L

ifelin

e is

the

low

est r

ate

avai

labl

e fo

r bas

ic

tele

phon

e se

rvic

e fro

m te

leph

one

serv

ice

prov

ider

s.

No

te:

NY

Sta

te L

aw p

rovi

des

for f

ine

or ja

il, o

r bot

h, fo

r a p

erso

n fo

und

guilt

y of

obt

aini

ng S

NA

P b

y hi

ding

the

fact

s or

not

tellin

g th

e tru

th.

SEC

TIO

N 9

: SN

AP A

UTH

OR

IZED

REP

RES

ENTA

TIVE

: If

you

wan

t som

eone

from

out

side

you

r ho

useh

old

to g

et th

e S

NA

P b

enef

its o

r to

bu

y th

e fo

od fo

r you

, PR

INT

thei

r nam

e, a

ddre

ss a

nd p

hone

num

ber.

SEC

TIO

N 1

0: S

IGN

ATU

RES

: S

ign

your

nam

e. If

you

are

an

Auth

oriz

ed R

epre

sent

ativ

e, b

oth

you

and

the

head

of h

ouse

hold

mus

t sig

n an

d da

te th

e si

gnat

ure

sect

ions

on

page

5 o

f the

App

licat

ion/

Rec

ertif

icat

ion.

W

hen

an A

utho

rized

Rep

rese

ntat

ive

is a

pply

ing

on b

ehal

f of a

SN

AP

Hou

seho

ld th

at d

oes

not r

esid

e in

an

inst

itutio

n, b

oth

the

Aut

horiz

ed

Rep

rese

ntat

ive

and

the

Hea

d of

Hou

seho

ld o

r ano

ther

resp

onsi

ble

adul

t mem

ber o

f the

hou

seho

ld m

ust s

ign

and

date

the

sign

atur

e se

ctio

ns

on P

age

5 of

the

App

licat

ion/

Rec

ertif

icat

ion.

SE

CTI

ON

11:

AD

DIT

ION

AL

INFO

RM

ATI

ON

: U

se th

is s

ectio

n to

let u

s kn

ow a

dditi

onal

info

rmat

ion

that

you

thin

k w

e m

ight

nee

d to

kno

w.

SEC

TIO

N 1

2: C

ON

SEN

T TO

WIT

HD

RAW

: If

you

dec

ide

you

no lo

nger

wis

h to

app

ly fo

r S

NA

P, s

ign

your

nam

e an

d en

ter

date

. You

may

re

appl

y at

any

tim

e.

No

te:

The

last

pag

e of

this

app

licat

ion

is a

n ap

plic

atio

n to

reg

iste

r to

vot

e. If

you

wou

ld li

ke h

elp

fillin

g ou

t the

vot

er r

egis

trat

ion

appl

icat

ion

form

, ask

you

r w

orke

r. A

pply

ing

or d

eclin

ing

to r

egis

ter

to v

ote

will

not

affe

ct y

our

elig

ibili

ty o

r th

e am

ount

of

assi

stan

ce th

at y

ou w

ill b

e gi

ven

by th

is a

genc

y.

Info

rmat

ion

from

you

r ap

plic

atio

n an

d in

terv

iew

will

be

ente

red

and

stor

ed in

the

Wel

fare

Man

agem

ent

Sys

tem

(W

MS

), a

stat

ewid

e co

mpu

ter

syst

em.

This

sys

tem

is u

sed

to im

prov

e th

e m

anag

emen

t of

Soc

ial

Ser

vice

s P

rogr

ams

and

to d

eter

fra

ud.

LDSS

-482

6A (R

ev. 8

/12)

P

age

5

R

EAD

TH

E IM

POR

TAN

T IN

FOR

MA

TIO

N B

ELO

W

APP

LIC

AN

T/R

ECIP

IEN

T R

IGH

TS A

ND

RES

PON

SIB

ILIT

IES

FOR

SN

AP

A

dditi

onal

info

rmat

ion

rega

rdin

g yo

ur ri

ghts

and

resp

onsi

bilit

ies

is c

onta

ined

in th

e C

lient

Info

rmat

ion

Boo

ks (L

DSS

-414

8A; L

DSS

-41

48B

and

LD

SS-4

148C

). T

hese

boo

ks c

an b

e ob

tain

ed a

t you

r soc

ial s

ervi

ces

dist

rict.

AS

AN

AP

PL

ICA

NT

/RE

CIP

IEN

T O

F S

NA

P Y

OU

HA

VE

RIG

HT

S:

TO

HA

VE

AN

IN

TE

RV

IEW

:

Th

e in

terv

iew

mus

t be

sche

dule

d as

pro

mpt

ly a

s po

ssib

le in

ord

er to

det

erm

ine

elig

ibilit

y an

d to

issu

e be

nefit

s w

ithin

30

days

of a

pplic

atio

n fil

ing.

You

may

brin

g so

meo

ne to

you

r int

ervi

ew to

inte

rpre

t for

you

. If y

ou n

eed

an in

terp

rete

r, th

e ag

ency

will

arra

nge

for o

ne. Y

ou c

anno

t be

deni

ed

acce

ss to

ser

vice

s be

caus

e yo

u ar

e no

t flu

ent i

n En

glis

h or

hea

ring

or s

peec

h im

paire

d.

Soci

al S

ervi

ces

dist

ricts

may

util

ize

the

TTY/

TTD

rela

y sy

stem

s to

gai

n ac

cess

to s

ervi

ces

for H

earin

g or

spe

ech

impa

ired

appl

ican

ts/re

cipi

ents

. If

you

have

any

spe

cial

nee

ds y

ou c

an re

ques

t spe

cial

acc

omm

odat

ions

from

you

r soc

ial s

ervi

ces

dist

rict.

If

you

have

a d

isab

ility,

you

hav

e th

e sa

me

right

to a

cces

s an

d be

inte

rvie

wed

for S

NAP

as

som

eone

who

doe

s no

t hav

e a

disa

bilit

y.

Yo

u m

ust b

e to

ld, w

ithin

30

days

of t

he d

ate

you

turn

ed in

(file

d) y

our

Appl

icat

ion

for

SNAP

, if y

our

Appl

icat

ion

is a

ppro

ved

or d

enie

d. I

f you

are

el

igib

le fo

r exp

edite

d pr

oces

sing

you

mus

t be

told

with

in 5

day

s af

ter t

he d

ate

you

turn

ed in

(file

d) y

our A

pplic

atio

n if

you

are

qual

ified

for S

NAP

.

You

may

requ

est t

hat t

he in

-offi

ce in

terv

iew

be

wai

ved

in h

ards

hip

situ

atio

ns. H

ards

hip

gene

rally

incl

udes

, but

is n

ot li

mite

d to

, illn

ess,

tra

nspo

rtatio

n di

fficu

lties

, car

e of

a h

ouse

hold

mem

ber,

hard

ship

due

to re

side

ncy

in a

rura

l are

a, p

rolo

nged

sev

ere

wea

ther

, or w

ork

or tr

aini

ng

hou

rs t

hat p

reve

nt yo

u f

rom

com

ing

in

during

th

e s

ocia

l se

rvic

es d

istr

ict’s o

ffic

e h

ours

. Th

e in

-offi

ce in

terv

iew

will

be

wai

ved,

at y

our r

eque

st, i

f al

l the

adu

lt m

embe

rs o

f you

r hou

seho

ld a

re e

lder

ly o

r dis

able

d w

ith n

o ea

rned

inco

me.

The

age

ncy

may

wai

ve th

e in

-offi

ce in

terv

iew

in

favo

r of a

tele

phon

e in

terv

iew

or s

ched

uled

hom

e vi

sit.

In-p

erso

n in

terv

iew

s m

ay b

e sc

hedu

led

in a

dvan

ce a

t any

mut

ually

acc

epta

ble

loca

tion

incl

udin

g a

ho

useh

old

’s r

esid

en

ce.

G

et a

writ

ten

notic

e te

lling

you

if yo

ur a

pplic

atio

n fo

r SN

AP is

app

rove

d or

den

ied:

--

I

f you

r App

licat

ion

is a

ppro

ved,

this

not

ice

will

tell

you

the

amou

nt o

f SN

AP b

enef

its y

ou w

ill ge

t;

--

If

your

App

licat

ion

is d

enie

d, th

is n

otic

e w

ill te

ll yo

u w

hy a

nd w

hat y

ou s

houl

d do

if y

ou d

isag

ree

or d

o no

t und

erst

and

this

dec

isio

n.

TO A

CO

NFE

REN

CE

AN

D/O

R F

AIR

HEA

RIN

G

If yo

u th

ink

any

deci

sion

abo

ut y

our c

ase

is w

rong

, or y

ou d

o no

t und

erst

and

any

deci

sion

, tal

k to

you

r wor

ker r

ight

aw

ay.

If yo

u st

ill di

sagr

ee o

r do

not

unde

rsta

nd, y

ou h

ave

the

right

to a

Con

fere

nce

and/

or a

Fai

r Hea

ring.

C

ON

FER

ENC

E - A

Con

fere

nce

is w

hen

you

mee

t with

som

eone

oth

er th

an th

e pe

rson

who

mad

e th

e de

cisi

on a

bout

you

r cas

e. A

t the

Con

fere

nce

this

per

son

will

revi

ew th

at d

ecis

ion.

Som

etim

es a

Con

fere

nce

is th

e fa

stes

t way

to s

olve

any

pro

blem

s yo

u m

ay h

ave.

We

enco

urag

e yo

u to

ask

for

one

even

if y

ou h

ave

requ

este

d a

Fair

Hea

ring.

H

owev

er, C

onfe

renc

es a

re v

olun

tary

, and

you

can

requ

est a

Fai

r Hea

ring

even

if y

ou d

o no

t re

ques

t a C

onfe

renc

e. T

o as

k fo

r a C

onfe

renc

e, c

all o

r writ

e yo

ur s

ocia

l ser

vice

s di

stric

t. A

CO

NFE

REN

CE

IS N

OT

A FA

IR H

EAR

ING

. If y

ou a

re to

ld th

at y

our c

ase

is b

eing

clo

sed,

or t

hat y

our S

NAP

ben

efits

or o

ther

hel

p yo

u ar

e ge

tting

w

ill ch

ange

, and

the

prob

lem

is n

ot s

ettle

d th

roug

h a

Con

fere

nce,

you

mus

t ask

for a

Fai

r Hea

ring

to k

eep

your

SN

AP b

enef

its o

r oth

er h

elp

you

are

getti

ng fr

om b

eing

sto

pped

or c

hang

ed.

Yo

ur

tim

e t

o r

eq

uest

a f

air h

earin

g a

nd

yo

ur

rig

ht to

“a

id to c

ontin

ue

” w

ill n

ot

be e

xte

nd

ed

by r

eq

uestin

g o

r ha

ving

a c

onfe

renc

e.

NO

TE:

A re

ques

t for

a C

onfe

renc

e is

not

a re

ques

t for

a F

air H

earin

g. If

you

wan

t a F

air H

earin

g, y

ou m

ust r

eque

st o

ne.

LDSS

-482

6A (R

ev. 8

/12)

P

age

6

REA

D T

HE

IMPO

RTA

NT

INFO

RM

ATI

ON

BEL

OW

(cont’d)

FA

IR H

EAR

ING

- A

Fair

Hea

ring

is a

cha

nce

for y

ou to

tell

an A

dmin

istra

tive

Law

Jud

ge fr

om th

e N

ew Y

ork

Stat

e O

ffice

of T

empo

rary

and

Dis

abili

ty

Assi

stan

ce w

hy y

ou th

ink

the

deci

sion

abo

ut y

our c

ase

was

wro

ng. T

he S

tate

will

then

issu

e a

writ

ten

deci

sion

whi

ch w

ill st

ate

whe

ther

the

soci

al

serv

ices

dis

tric

t’s d

ecis

ion

was

righ

t or w

rong

. The

writ

ten

deci

sion

may

ord

er th

e so

cial

ser

vice

s di

stric

t to

corr

ect y

our c

ase.

At

a F

air H

earin

g yo

u w

ill h

ave

a ch

ance

to e

xpla

in w

hy y

ou th

ink

the

deci

sion

is w

rong

.

TIM

E LI

MIT

S TO

ASK

FO

R A

FAI

R H

EAR

ING

- If

you

wan

t to

ask

for a

Fai

r Hea

ring

for S

NAP

, cal

l rig

ht a

way

bec

ause

ther

e ar

e tim

e lim

its. I

f you

w

ait t

oo lo

ng, y

ou m

ay n

ot b

e ab

le to

get

a F

air H

earin

g.

NO

TE:

If yo

ur s

ituat

ion

is v

ery

serio

us, t

he N

ew Y

ork

Stat

e O

ffice

of T

empo

rary

and

Dis

abilit

y As

sist

ance

will

set u

p a

Fair

Hea

ring

for y

ou a

s so

on a

s po

ssib

le. W

hen

you

call

or w

rite

for a

Fai

r Hea

ring,

be

sure

to e

xpla

in th

at y

our s

ituat

ion

is v

ery

serio

us.

If

you

do g

et a

not

ice

abou

t you

r cas

e an

d yo

u w

ant t

o as

k fo

r a F

air H

earin

g, th

e no

tice

will

tell

you

how

muc

h tim

e yo

u ha

ve to

ask

for t

he F

air

Hea

ring.

Be

sure

to re

ad a

ll of

the

notic

e ca

refu

lly.

If yo

ur n

otic

e te

lls y

ou th

at y

our S

NAP

ben

efits

hav

e be

en d

enie

d, w

ill b

e st

oppe

d or

will

be

redu

ced,

you

may

ask

for a

Fai

r Hea

ring

with

in

90 d

ays

from

the

date

of t

he n

otic

e. Y

ou m

ay a

sk fo

r a F

air H

earin

g if

you

thin

k yo

u ar

e no

t get

ting

enou

gh S

NA

P be

nefit

s at

any

time

with

in

the

cert

ifica

tion

perio

d.

If yo

u do

not

get

a n

otic

e ab

out y

our c

ase,

and

you

r ben

efits

are

den

ied,

sto

pped

or r

educ

ed y

ou c

an a

lso

ask

for a

Fai

r Hea

ring.

H

OW

TO

AS

K F

OR

A F

AIR

HE

AR

ING

If

you

do g

et a

not

ice

abou

t you

r cas

e an

d yo

u w

ant t

o as

k fo

r a F

air H

earin

g, th

e no

tice

will

tell

you

how

. Be

sure

to re

ad a

ll of

the

notic

e ca

refu

lly.

If yo

u ge

t a n

otic

e te

lling

you

that

you

r ben

efits

will

be s

topp

ed o

r red

uced

, and

you

ask

for a

Fai

r Hea

ring

befo

re th

e ef

fect

ive

date

on

your

not

ice,

yo

ur m

oney

or o

ther

hel

p w

ill, in

mos

t ins

tanc

es, s

tay

the

sam

e ("

aid

cont

inui

ng")

unt

il th

e Fa

ir H

earin

g de

cisi

on is

mad

e. If

the

notic

e w

as n

ot s

ent

befo

re th

e ef

fect

ive

date

, and

you

ask

for a

Fai

r Hea

ring

with

in 1

0 da

ys o

f the

pos

tmar

k da

te o

f the

not

ice,

you

als

o ha

ve th

e rig

ht to

hav

e yo

ur m

oney

or

oth

er h

elp

stay

the

sam

e ("

aid

cont

inui

ng")

unt

il th

e Fa

ir H

earin

g de

cisi

on is

mad

e.

How

ever

, if y

ou d

o ge

t "ai

d co

ntin

uing

" an

d yo

u lo

se th

e Fa

ir H

earin

g, y

ou w

ill ha

ve to

pay

bac

k an

y be

ne

fits

th

at yo

u r

ece

ive

d a

s “

aid

co

ntin

uin

g”

whi

le w

aitin

g fo

r the

Fai

r Hea

ring

deci

sion

.

If yo

u do

not

wan

t the

mon

ey o

r oth

er h

elp

you

have

bee

n ge

tting

to s

tay

the

sam

e un

til th

e Fa

ir H

earin

g de

cisi

on is

mad

e, y

ou m

ust t

ell t

his

to th

e N

ew Y

ork

Stat

e O

ffice

of T

empo

rary

and

Dis

abilit

y As

sist

ance

whe

n yo

u ca

ll or

writ

e fo

r a F

air H

earin

g.

If yo

u do

not

get

a n

otic

e ab

out y

our c

ase,

and

you

r ben

efits

are

sto

pped

or r

educ

ed, y

ou c

an s

till a

sk fo

r a F

air H

earin

g. A

t the

sam

e tim

e th

at y

ou

ask

for a

Fai

r Hea

ring,

you

can

ask

that

you

r mon

ey o

r oth

er h

elp

be re

stor

ed ("

aid

cont

inui

ng")

.

LDSS

-482

6A (R

ev. 8

/12)

P

age

7

R

EAD

TH

E IM

POR

TAN

T IN

FOR

MA

TIO

N B

ELO

W (c

ont’d)

WH

AT

YOU

SH

OU

LD D

O F

OR

A F

AIR

HEA

RIN

G

The

New

Yor

k St

ate

Offi

ce o

f Tem

pora

ry a

nd D

isab

ility

Assi

stan

ce w

ill se

nd y

ou a

not

ice,

whi

ch te

lls y

ou w

hen

and

whe

re th

e Fa

ir H

earin

g w

ill be

he

ld.

To h

elp

you

get r

eady

for t

he F

air H

earin

g, y

ou h

ave

the

right

to lo

ok a

t you

r cas

e re

cord

and

get

free

cop

ies

of th

e fo

rms

and

pape

rs w

hich

will

be

give

n to

the

Adm

inis

trativ

e La

w J

udge

at t

he F

air H

earin

g. Y

ou c

an a

lso

get f

ree

copi

es o

f any

oth

er p

aper

s in

you

r cas

e re

cord

whi

ch y

ou th

ink

you

may

nee

d fo

r the

Fai

r Hea

ring.

Usu

ally

, you

can

get

thes

e pa

pers

bef

ore

the

hear

ing

or a

t the

hea

ring

at th

e la

test

. If

you

ask

for a

ny p

aper

s, a

nd th

e so

cial

ser

vice

s di

stric

t doe

s no

t giv

e th

em to

you

bef

ore

or a

t the

hea

ring,

you

sho

uld

tell

the

Adm

inis

trativ

e La

w J

udge

abo

ut it

. Yo

u ca

n br

ing

a la

wye

r, a

rela

tive

or a

frie

nd to

the

Fair

Hea

ring

to h

elp

you

expl

ain

why

you

thin

k a

deci

sion

abo

ut y

our c

ase

is w

rong

. If y

ou c

anno

t go

to th

e Fa

ir H

earin

g, y

ou c

an s

end

som

eone

els

e in

you

r pla

ce. I

f you

are

sen

ding

som

eone

who

is n

ot a

law

yer t

o th

e Fa

ir H

earin

g, y

ou s

houl

d gi

ve

this

per

son

a le

tter t

o gi

ve to

the

Adm

inis

trativ

e La

w J

udge

. Thi

s le

tter s

houl

d te

ll th

e Ju

dge

that

this

per

son

is ta

king

you

r pla

ce.

To h

elp

you

expl

ain

at th

e Fa

ir H

earin

g w

hy y

ou th

ink

the

deci

sion

is w

rong

, you

sho

uld

also

brin

g an

y w

itnes

ses

who

can

hel

p yo

u an

d an

y in

form

atio

n yo

u ha

ve s

uch

as:

Pay

stub

s

Bill

s

R

ecei

pts

Le

ases

Do

cto

r’s S

tate

me

nts

So

meo

ne fr

om th

e so

cial

ser

vice

s di

stric

t will

also

be

at th

e Fa

ir H

earin

g to

exp

lain

the

deci

sion

abo

ut y

our c

ase.

You

or y

our r

epre

sent

ativ

e w

ill be

ab

le to

que

stio

n th

is p

erso

n an

d pr

esen

t you

r sid

e of

the

case

. You

or y

our r

epre

sent

ativ

e w

ill al

so b

e ab

le to

que

stio

n an

y w

itnes

ses

who

you

brin

g to

he

lp y

ou.

If

you

thin

k yo

u ne

ed a

law

yer t

o he

lp y

ou w

ith y

our F

air H

earin

g, y

ou m

ay b

e ab

le to

get

a la

wye

r at n

o co

st to

you

by

calli

ng y

our l

ocal

Leg

al A

id o

r Le

gal S

ervi

ces

Offi

ce. F

or th

e na

mes

of o

ther

law

yers

, cal

l you

r loc

al B

ar A

ssoc

iatio

n.

NO

TE:

If yo

u as

k, y

ou w

ill be

abl

e to

get

bac

k th

e m

oney

you

had

to p

ay fo

r pub

lic tr

ansp

orta

tion,

chi

ld c

are

and

othe

r nec

essa

ry e

xpen

ses

to

go to

the

fair

hear

ing.

If n

o pu

blic

tran

spor

tatio

n is

ava

ilabl

e, y

ou m

ay b

e ab

le to

get

bac

k th

e m

oney

you

had

to p

ay fo

r ano

ther

type

of

trans

porta

tion.

If y

ou a

re u

nabl

e to

use

pub

lic tr

ansp

orta

tion

beca

use

of a

med

ical

pro

blem

, you

may

be

able

to g

et b

ack

the

mon

ey y

ou

had

to p

ay fo

r ano

ther

type

of t

rans

porta

tion.

How

ever

, you

may

be

aske

d to

pro

vide

med

ical

ver

ifica

tion.

If yo

u liv

e an

ywhe

re in

New

Yor

k St

ate,

you

may

requ

est a

Fai

r Hea

ring

by te

leph

one,

fax,

onl

ine,

or b

y w

ritin

g to

th

e ad

dres

s be

low

.

Tele

phon

e: S

tate

wid

e to

ll fre

e re

ques

t num

ber i

s 80

0-34

2-33

34.

Plea

se h

ave

the

notic

e, if

any

, with

you

whe

n yo

u ca

ll.

Fax:

you

r Fai

r Hea

ring

Req

uest

to:

518-

473-

6735

O

nlin

e: C

ompl

ete

onlin

e re

ques

t for

m a

t http

://w

ww

.otd

a.st

ate.

ny.u

s.us

/oah

/form

s.as

p

LDSS

-482

6A (R

ev. 8

/12)

P

age

8

REA

D T

HE

IMPO

RTA

NT

INFO

RM

ATI

ON

BEL

OW

(cont’d)

In

writ

ing:

For

not

ices

, fill

in th

e su

pplie

d sp

ace

and

send

a c

opy

of th

e no

tice,

or w

rite

to:

Fa

ir H

earin

g Se

ctio

n N

YS O

ffice

of T

empo

rary

and

Dis

abili

ty A

ssis

tanc

e Fa

ir H

earin

gs

P.

O. B

ox 1

930

Alb

any,

New

Yor

k 12

201-

1930

P

lease

ke

ep

a c

opy o

f a

ny n

otice f

or

yo

urs

elf

If yo

u liv

e in

New

Yor

k C

ity y

ou m

ay a

lso

mak

e yo

ur re

ques

t in

pers

on b

y w

alki

ng in

to th

e of

fice

liste

d be

low

. W

alk-

In (N

ew Y

ork

City

Onl

y)

Brin

g a

copy

of t

he n

otic

e, o

r ask

for a

hea

ring

on a

mat

ter n

ot b

ased

on

a no

tice,

to:

O

ffice

of A

dmin

istr

ativ

e H

earin

gs

Offi

ce o

f Tem

pora

ry &

Dis

abili

ty A

ssis

tanc

e

14 B

oeru

m P

lace

B

rook

lyn,

New

Yor

k

NO

TE:

For N

ew Y

ork

City

em

erge

ncy

fair

hear

ings

onl

y – C

all 8

00-2

05-0

110.

Do

not u

se th

is te

leph

one

num

ber f

or a

nyth

ing

exce

pt

emer

genc

ies.

Req

uest

s th

at d

o no

t inv

olve

em

erge

ncie

s w

ill no

t be

take

n at

this

num

ber.

TO

LO

OK

AT

YO

UR

CA

SE

AN

D C

OM

PU

TE

R R

EC

OR

DS

: O

nce

you

appl

y fo

r SN

AP o

r oth

er h

elp,

cas

e re

cord

s an

d co

mpu

ter r

ecor

ds a

re k

ept a

bout

you

r cas

e. U

sual

ly, y

ou h

ave

the

right

to lo

ok a

t tho

se re

cord

s.

How

ever

, you

may

not

be

able

to lo

ok a

t all

of th

e re

cord

s. Y

our w

orke

r can

exp

lain

the

rule

s to

you

.

Whe

n yo

u w

rite

for c

opie

s of

you

r com

pute

r rec

ords

, the

Per

sona

l Priv

acy

Prot

ectio

n La

w re

quire

s th

at N

ew Y

ork

Stat

e ag

enci

es, s

end

you

your

reco

rds;

or

tell

you

why

they

will

not g

ive

you

your

reco

rds;

or

tell

you

they

hav

e yo

ur re

ques

t and

they

will

det

erm

ine

if yo

u ar

e al

low

ed to

get

you

r rec

ords

with

in

five

wor

king

day

s of

whe

n th

ey g

et y

our r

eque

st le

tter.

R

EG

AR

DIN

G E

MP

LO

YM

EN

T:

If yo

u do

not

agr

ee th

at y

ou a

re a

ble

to w

ork,

you

sho

uld

notif

y th

e so

cial

ser

vice

s di

stric

t tha

t you

bel

ieve

you

sho

uld

be e

xem

pt fr

om p

artic

ipat

ion

in

wor

k ac

tiviti

es.

You

will

be n

otifi

ed o

f the

soc

ial s

ervi

ces

dis

tric

t’s d

eter

min

atio

n re

gard

ing

your

cla

im.

If th

e so

cial

ser

vice

s di

stric

t dis

agre

es w

ith y

ou,

you

may

requ

est a

fair

hear

ing

to te

ll an

Adm

inis

trativ

e La

w J

udge

why

you

thin

k yo

u ar

e no

t abl

e to

wor

k.

If yo

u ar

e re

quire

d to

par

ticip

ate

in S

NAP

wor

k ac

tiviti

es, y

ou m

ay b

e ab

le to

get

hel

p pa

ying

for c

erta

in w

ork-

rela

ted

expe

nses

. Yo

u al

so m

ay b

e ab

le

to re

ceiv

e as

sist

ance

with

chi

ld c

are

cost

s.

IF Y

OU

AR

E SU

SPEC

TED

OF

FRAU

D

If yo

u fin

d ou

t tha

t you

are

bei

ng in

vest

igat

ed b

ecau

se y

our w

orke

r thi

nks

you

did

not t

ell t

he tr

uth

abou

t you

r cas

e, y

ou s

houl

d ta

lk to

a la

wye

r. If

you

are

char

ged

with

wel

fare

frau

d in

crim

inal

cou

rt, th

e co

urt w

ill, if

you

are

elig

ible

, ass

ign

a la

wye

r to

repr

esen

t you

at n

o co

st.

LDSS

-482

6A (R

ev. 8

/12)

P

age

9

REA

D T

HE

IMPO

RTA

NT

INFO

RM

ATI

ON

BEL

OW

(cont’d)

AS

AN

AP

PL

ICA

NT

/RE

CIP

IEN

T O

F S

NA

P Y

OU

HA

VE

SE

VE

RA

L R

ES

PO

NS

IBIL

ITIE

S:

EM

PL

OY

ME

NT

RE

SP

ON

SIB

ILIT

IES

FO

R S

NA

P R

EC

IPIE

NT

S:

Unl

ess

you

are

exem

pt fr

om w

ork

requ

irem

ents

as

an a

pplic

ant f

or o

r rec

ipie

nt o

f SN

AP y

ou m

ust c

ompl

y w

ith c

erta

in ru

les,

incl

udin

g pa

rtici

patio

n in

w

ork

activ

ities

and

acc

eptin

g a

job.

You

r wor

ker w

ill ex

plai

n th

ese

rule

s.

If

you

do n

ot c

ompl

y w

ith th

e w

ork

requ

irem

ents

, you

may

lose

you

r SN

AP

bene

fits.

Th

ere

are

seve

ral e

xem

ptio

ns fr

om p

artic

ipat

ion

in S

NAP

wor

k re

quire

men

ts.

Ask

your

wor

ker i

f you

qua

lify

for o

ne o

f the

exe

mpt

ions

. Yo

u m

ay b

e re

quire

d to

pro

vide

doc

umen

tatio

n to

sup

port

your

cla

im.

If yo

u ar

e no

t exe

mpt

from

par

ticip

atio

n in

wor

k ac

tiviti

es a

nd d

o no

t com

ply

with

the

wor

k re

quire

men

ts, y

ou m

ay lo

se y

our S

NAP

ben

efits

. The

leng

th

of ti

me

you

will

lose

you

r ben

efits

dep

ends

on

the

num

ber o

f tim

es y

ou h

ave

faile

d to

com

ply.

AD

DIT

ION

AL

RE

SP

ON

SIB

ILIT

IES

AN

D R

EQ

UIR

EM

EN

TS

FO

R S

NA

P R

EC

IPIE

NT

S W

HO

AR

E A

BL

E-B

OD

IED

AD

UL

TS

WIT

HO

UT

DE

PE

ND

EN

TS

(A

BA

WD

S)

If yo

u ar

e an

abl

e-bo

died

wor

k re

gist

rant

, you

may

als

o be

req

uire

d to

mee

t add

ition

al S

NAP

elig

ibilit

y re

quire

men

ts.

Your

wor

ker

will

expl

ain

thes

e re

quire

men

ts a

nd th

e ex

empt

ions

from

the

requ

irem

ents

.

If yo

u ar

e a

wor

k re

gist

rant

and

not

exe

mpt

, you

will

only

be

elig

ible

to r

ecei

ve S

NA

P be

nefit

s fo

r th

ree

mon

ths

in e

very

36

mon

ths

unle

ss y

ou a

re

mee

ting

the

addi

tiona

l req

uire

men

ts.

If

you

wan

t to

cont

inue

to re

ceiv

e SN

AP b

enef

its b

eyon

d th

e th

ree

mon

th li

mit,

you

sho

uld

ask

your

wor

ker f

or a

qua

lifyi

ng w

ork

or tr

aini

ng o

ppor

tuni

ty.

If

you

lose

you

r el

igib

ility

for

SNAP

bec

ause

you

did

not

mee

t the

add

ition

al r

equi

rem

ent f

or th

ree

or m

ore

mon

ths

durin

g w

hich

you

rec

eive

d S

NAP

be

nefit

s, y

ou m

ay b

e ab

le to

re-e

stab

lish

your

elig

ibilit

y in

sev

eral

diff

eren

t way

s. Y

our w

orke

r will

expl

ain

how

to d

o th

is.

RES

PON

SIB

ILIT

Y TO

RES

CH

EDU

LE A

MIS

SED

INTE

RVI

EW:

As a

n Ap

plic

ant/R

ecip

ient

of S

NAP

, you

hav

e th

e re

spon

sibi

lity

of re

sche

dulin

g a

mis

sed

inte

rvie

w b

efor

e th

e 30

th d

ay a

fter t

he d

ate

you

appl

ied

to a

void

lo

sing

SN

AP.

RES

PON

SIB

ILIT

Y TO

PR

OVI

DE

PRO

OF

W

hen

you

are

appl

ying

for

or g

ettin

g he

lp, y

ou w

ill be

ask

ed to

pro

vide

pro

of o

f cer

tain

thin

gs. Y

our

wor

ker

will

tell

you

whi

ch o

f the

se th

ings

you

mus

t pr

ove.

Not

all

of th

ese

thin

gs a

re re

quire

d fo

r eve

ry p

rogr

am.

You

may

hav

e to

pro

ve s

ome

thin

gs fo

r one

pro

gram

and

not

for a

noth

er.

If yo

u br

ing

proo

f with

you

whe

n yo

u fir

st c

ome

in to

app

ly fo

r ass

ista

nce,

you

may

be

able

to g

et h

elp

soon

er.

If yo

u dr

op d

ocum

enta

tion

off a

t the

soc

ial s

ervi

ces

dist

rict,

you

shou

ld a

sk fo

r a re

ceip

t to

prov

e w

hat d

ocum

enta

tion

you

left.

The

rece

ipt s

houl

d ha

ve

your

nam

e, th

e sp

ecifi

c do

cum

enta

tion

that

you

dro

pped

off,

the

time,

dat

e, d

istri

ct n

ame

and

the

nam

e of

the

soci

al s

ervi

ces

wor

ker w

ho p

rovi

ded

the

rece

ipt.

LDSS

-482

6A (R

ev. 8

/12)

P

age

10

REA

D T

HE

IMPO

RTA

NT

INFO

RM

ATI

ON

BEL

OW

(cont’d)

If yo

u ca

nnot

get

the

proo

f you

nee

d, a

sk y

our w

orke

r to

help

you

. If

the

soci

al s

ervi

ces

dist

rict a

lread

y ha

s pr

oof o

f the

thin

gs th

at d

o no

t cha

nge,

suc

h as

yo

ur s

ocia

l sec

urity

num

ber,

you

do n

ot n

eed

to p

rove

them

aga

in.

If yo

ur w

orke

r tel

ls y

ou th

at y

ou n

eed

addi

tiona

l pap

ers

and

info

rmat

ion

to fi

nd o

ut if

you

can

get

hel

p, y

ou m

ust p

rovi

de th

at p

roof

. If

you

cann

ot g

et th

ese

pape

rs a

nd in

form

atio

n, y

our w

orke

r mus

t try

to h

elp

you.

N

ON

-CIT

IZE

N E

LIG

IBIL

ITY

IN

FO

RM

AT

ION

M

any

non-

citiz

ens

are

qual

ified

alie

ns w

ho a

re e

ligib

le fo

r SN

AP. E

ven

if yo

u ar

e no

t, yo

ur c

hild

ren

may

be

elig

ible

. SN

AP s

houl

d no

t affe

ct y

our

imm

igra

tion

stat

us w

ith re

spec

t to

any

USC

IS d

ecis

ion

rega

rdin

g yo

ur im

mig

ratio

n m

atte

r.

Yo

u m

ay b

e el

igib

le fo

r SN

AP if

you

are

a U

nite

d St

ates

(U.S

.) ci

tizen

, a

non-

citiz

en U

.S. n

atio

nal (

peop

le b

orn

in A

mer

ican

Sam

oa o

r Sw

ain

Isla

nd),

or

a qu

alifi

ed a

lien.

A q

ualif

ied

alie

n fo

r SN

AP e

ligib

ility

is:

1.

An

Am

eric

an In

dian

bor

n in

Can

ada

with

at l

east

50

per c

entu

m o

f blo

od o

f the

Am

eric

an In

dian

race

und

er s

ectio

n 28

9 of

the

Imm

igra

tion

and

Nat

iona

lity

Act (

INA)

, or

2.

A m

embe

r of a

n In

dian

trib

e th

at is

a fe

dera

lly re

cogn

ized

Indi

an tr

ibe

(25

U.S

.C. (

450b

(e)),

or

3.

An a

lien

adm

itted

as

a H

mon

g or

Hig

hlan

d La

otia

n, in

clud

ing

spou

se a

nd d

epen

dent

chi

ld, o

r 4.

A

refu

gee

adm

itted

und

er s

ectio

n 20

7 of

the

INA,

or

5.

An

alie

n gr

ante

d as

ylum

und

er s

ectio

n 20

8 of

the

INA,

or

6.

An a

lien

who

se d

epor

tatio

n ha

s be

en w

ithhe

ld u

nder

sec

tion

234(

h) o

f the

INA

as in

effe

ct p

rior t

o Ap

ril 1

, 199

7, o

r rem

oval

with

held

und

er

sect

ion

241(

b)(3

) of t

he IN

A, o

r 7.

An

alie

n ad

mitt

ed a

s a

Cub

an o

r Hai

tian

entra

nt, o

r

8.

An a

lien

who

is a

vic

tim o

f tra

ffick

ing

unde

r sec

tion

103(

8) o

f the

Tra

ffick

ing

Vict

ims

Prot

ectio

n A

ct, o

r

9.

An a

lien

who

is o

n ac

tive

duty

in th

e U

.S. a

rmed

forc

es o

r, an

hon

orab

ly d

isch

arge

d v

eter

an, t

heir

spou

se a

nd d

epen

dent

chi

ldre

n, a

nd th

e un

-rem

arrie

d su

rviv

ing

spou

se a

nd u

nmar

ried

depe

nden

t chi

ldre

n of

an

activ

e du

ty m

embe

r or v

eter

an w

ho h

as d

ied,

or

10.

An a

lien

adm

itted

as

an A

mer

iasi

an, o

r 11

. An

alie

n la

wfu

lly a

dmitt

ed fo

r per

man

ent r

esid

ence

und

er th

e IN

A a

nd w

ho h

as 5

yea

rs in

sta

tus,

or

12.

An a

lien

paro

led

unde

r sec

tion

212(

d)(5

) of t

he IN

A fo

r at l

east

1 y

ear a

nd w

ho h

as 5

yea

rs in

sta

tus,

or

13.

An a

lien

or p

aren

t or c

hild

of a

n al

ien

who

has

bee

n ba

ttere

d or

sub

ject

ed to

ext

rem

e cr

uelty

in th

e U

.S. b

y a

fam

ily m

embe

r and

ent

ered

th

e U

.S. b

efor

e 8/

22/9

6 or

has

5 y

ears

in s

tatu

s, o

r

14.

Alie

ns a

lso

may

be

elig

ible

for S

NAP

if:

They

are

law

fully

adm

itted

for p

erm

anen

t res

iden

ce a

nd h

ave

earn

ed, o

r can

be

cred

ited

with

40

quar

ters

of w

ork;

They

are

in

a qu

alifi

ed s

tatu

s lis

ted

abov

e an

d re

ceiv

e ce

rtain

dis

abilit

y or

blin

dnes

s be

nefit

s;

Th

ey a

re in

a q

ualif

ied

stat

us li

sted

abo

ve a

nd a

re u

nder

18

year

s ol

d;

Th

ey a

re la

wfu

lly in

the

U.S

. on

Augu

st 2

2, 1

996

and

are

now

blin

d or

dis

able

d, o

ld, o

r was

bor

n on

or b

efor

e A

ugus

t 22,

193

1.

NEW

YO

RK

STA

TE O

FFIC

E O

F TE

MP

OR

AR

Y A

ND

DIS

AB

ILIT

Y A

SS

ISTA

NC

E

SUPP

LEM

ENTA

L N

UTR

ITIO

N A

SSIS

TAN

CE

PRO

GR

AM

(S

NA

P) A

PPLI

CA

TIO

N/R

ECER

TIFI

CAT

ION

SN

AP

is

th

e n

ew

nam

e f

or

the

Fo

od

Sta

mp

Pro

gra

m

Use

th

is f

orm

if

Ap

ply

ing

Fo

r S

NA

P O

nly

If yo

u ar

e on

ly a

pply

ing

for

SNAP

you

can

use

this

sho

rter a

pplic

atio

n. If

you

wou

ld li

ke to

app

ly fo

r oth

er b

enef

its s

uch

as T

empo

rary

Ass

ista

nce,

C

hild

Car

e A

ssis

tanc

e, H

ome

Ener

gy A

ssis

tanc

e or

Med

icai

d pl

ease

ask

for a

diff

eren

t app

licat

ion.

T

his

app

lica

tion

ca

n o

nly

be u

sed t

o a

pp

ly fo

r S

NA

P.

Wh

en

Yo

u A

re A

pp

lyin

g F

or

SN

AP

Yo

u ca

n fil

e an

app

licat

ion

the

sam

e da

y yo

u re

ceiv

e it.

If y

ou a

re e

ligib

le, b

enef

its w

ill be

pro

vide

d ba

ck to

the

filin

g da

te o

f you

r app

licat

ion.

You

can

file

your

app

licat

ion

befo

re y

ou h

ave

an in

terv

iew

.

We

mus

t ac

cept

you

r ap

plic

atio

n if,

at

a m

inim

um,

it co

ntai

ns y

our

nam

e, a

ddre

ss (

if yo

u ha

ve o

ne),

and

a si

gnat

ure.

Thi

s in

form

atio

n w

ill es

tabl

ish

your

ap

plic

atio

n fil

ing

date

. How

ever

, the

app

licat

ion

proc

ess,

incl

udin

g th

e in

terv

iew

and

a s

igna

ture

on

page

5 o

f the

app

licat

ion/

rece

rtific

atio

n m

ust b

e co

mpl

eted

fo

r us

to d

eter

min

e yo

ur e

ligib

ility.

You

can

appl

y fo

r and

get

SN

AP

for e

ligib

le h

ouse

hold

mem

ber(

s) e

ven

if yo

u or

som

e ot

her m

embe

rs o

f you

r hou

seho

ld a

re n

ot e

ligib

le fo

r ben

efits

bec

ause

of

imm

igra

tion

stat

us. F

or e

xam

ple,

inel

igib

le a

lien

pare

nts

can

appl

y fo

r SN

AP

for t

heir

child

ren

and

rece

ive

bene

fits

for t

heir

elig

ible

chi

ldre

n.

Yo

u ca

n st

ill ap

ply

and

be e

ligib

le fo

r SN

AP

even

if y

ou h

ave

reac

hed

your

Tem

pora

ry A

ssis

tanc

e tim

e lim

its.

Ne

ed

SN

AP

Ben

efi

ts R

igh

t A

wa

y?

Yo

u M

ay

Be

Eli

gib

le F

or

Ex

ped

ited

Pro

ces

sin

g o

f y

ou

r S

NA

P A

pp

lic

ati

on

. If

your

hou

seho

ld h

as li

ttle

or n

o in

com

e or

liqu

id re

sour

ces,

or i

f you

r ren

t and

util

ity e

xpen

ses

are

mor

e th

an y

our i

ncom

e an

d liq

uid

reso

urce

s, o

r yo

u ar

e a

mig

rant

or

seas

onal

farm

wor

ker

with

littl

e or

no

inco

me

or r

esou

rces

whe

n yo

u ap

ply,

you

may

be

qual

ified

to r

ecei

ve S

NAP

with

in 5

ca

lend

ar d

ays

afte

r the

dat

e th

at y

ou a

pply

. You

r wor

ker w

ill al

way

s re

view

you

r circ

umst

ance

s to

see

if y

ou a

re q

ualif

ied

for e

xped

ited

proc

essi

ng

of y

our S

NAP

app

licat

ion.

A p

roce

ss is

in p

lace

to is

sue

SNAP

ben

efits

to a

ll el

igib

le h

ouse

hold

s w

ho m

eet t

he s

tand

ards

for e

xped

ited

serv

ice.

W

he

re Y

ou

Can

Ap

ply

Fo

r S

NA

P

If yo

u liv

e ou

tsid

e of

New

Yor

k C

ity, c

all o

r vis

it th

e so

cial

ser

vice

s di

stric

t in

the

coun

ty w

here

you

live

and

ask

for a

n ap

plic

atio

n pa

ckag

e. Y

ou c

an

get t

he a

ddre

ss a

nd p

hone

num

ber b

y ca

lling

toll

free

1-80

0-34

2-30

09, o

r app

ly o

n-lin

e at

myB

enef

its.n

y.go

v.

If yo

u liv

e in

New

Yor

k C

ity a

nd y

ou a

re n

ot a

lso

appl

ying

for

Tem

pora

ry A

ssis

tanc

e, c

all o

r vi

sit

any

SNA

P O

ffice

and

ask

for

an

appl

icat

ion

pack

age.

Yo

u ca

n ge

t th

e ad

dres

s an

d ph

one

num

ber

by

calli

ng

1-71

8-55

7-13

99

or

toll

free

1-80

0-34

2-30

09,

or

appl

y on

-line

at

m

yBen

efits

.ny.

gov.

H

av

ing

Pro

ble

ms

Co

min

g T

o U

s F

or

A S

NA

P A

pp

oin

tmen

t?

If it

is d

iffic

ult f

or y

ou to

com

e in

for a

SN

AP a

pplic

atio

n ap

poin

tmen

t (re

ason

s m

ay in

clud

e em

ploy

men

t, he

alth

issu

es, t

rans

porta

tion

or c

hild

car

e pr

oble

ms)

, you

may

hav

e so

meo

ne e

lse

appl

y fo

r you

, or y

ou m

ay a

pply

on-

line

at m

yBen

efits

.ny.

gov.

You

als

o ca

n m

ail u

s yo

ur a

pplic

atio

n or

dro

p it

off a

nd, i

n so

me

circ

umst

ance

s; w

e ca

n in

terv

iew

you

by

tele

phon

e.

Pl

ease

con

tact

you

r soc

ial s

ervi

ces

dist

rict i

f you

hav

e an

y qu

estio

ns, t

o se

e if

you

are

elig

ible

for a

tele

phon

e in

terv

iew

, or

if y

ou

need

t

o r

es

ch

ed

ule

an

in

terv

iew

.

LDSS

-482

6 (R

ev.8

/12)

Pa

ge 1

N

EW Y

OR

K S

TATE

OFF

ICE

OF

TEM

PO

RA

RY

AN

D D

ISA

BIL

ITY

AS

SIS

TAN

CE

SN

AP

APP

LIC

ATI

ON

/ R

ECER

TIFI

CA

TIO

N

App

licat

ion

Dat

e In

terv

iew

Dat

e C

ente

r/O

ffice

U

nit

Wor

ker

Cas

e T

ype

Cas

e N

umbe

r R

egis

try

Num

ber

Ver

sion

L

ifelin

e

A

pply

Rec

ertif

y

Lan

g

Nam

e: _

____

____

____

____

____

____

Tel

epho

ne N

umbe

r: __

____

____

____

___O

ther

pho

ne w

here

you

can

be

reac

hed:

___

____

____

__

Res

iden

ce A

ddre

ss: _

____

____

____

____

____

____

____

Apt

.# _

___

City

___

____

____

____

____

, NY

Zip

Cod

e __

____

____

____

__

Mai

ling

Add

ress

(if d

iffer

ent)

____

____

____

____

____

___

Apt.#

___

_ C

ity _

____

____

____

____

__, N

Y Z

ip C

ode

____

____

____

____

O

ther

Nam

e: _

____

____

____

____

_ A

re Y

ou:

App

lyin

g o

r

Rec

ertif

ying

Do

you

wan

t to

rece

ive

notic

es in

:

Spa

nish

an

d E

nglis

h o

r

Eng

lish

On

ly

We

mus

t acc

ept y

our a

pplic

atio

n if,

at a

min

imum

, it c

onta

ins

you

r nam

e,

addr

ess

(if y

ou h

ave

one)

, and

sig

natu

re in

this

box

.

AP

PLI

CA

NT/

RE

PR

ESE

NTA

TIV

E S

IGN

ATU

RE

D

ATE

SIG

NE

D

Lis

t eve

ryon

e w

ho li

ves

with

you

eve

n if

they

are

not

app

lyin

g. L

ist y

ours

elf f

irst.

L N

Firs

t Nam

e M

I La

st N

ame

Soc

ial S

ecur

ity N

umbe

r (S

SN

) of a

pply

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mem

ber

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none, w

rite

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ON

E”)

D

ate

of B

irth

Mar

ital

Sta

tus

Sex

M

or

F

Is th

is

pers

on

appl

ying

? R

elat

ions

hip

to y

ou

Do

you

buy

and/

or

pre

pare

food

w

ith th

is

pers

on?

His

pani

c or

La

tino?

Ent

er Y

(Yes

) or N

(No)

for

each

race

*

Yes

N

o Ye

s N

o Ye

s N

o I

A

B

P W

U

1

se

lf

2

3

4

5

6

7

8

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e/E

thni

c C

odes

: I –

Nat

ive

Am

eric

an o

r A

lask

an N

ativ

e, A

- A

sian

, B

– B

lack

or

Afr

ican

Am

eric

an,

P –

Nat

ive

Haw

aiia

n or

Pac

ific

Isla

nder

, W

– W

hite

, U

– U

nkno

wn

(MA

On

ly)

Are

you

and

is e

very

one

livin

g w

ith y

ou a

US

citi

zen?

□

Yes

No

If

No,

who

is n

ot a

citi

zen?

Has

a c

ourt

issu

ed a

war

rant

bec

ause

it fo

und

that

you

or

anyo

ne li

ving

with

you

is fl

eein

g to

avo

id p

rose

cutio

n, c

usto

dy o

r co

nfin

emen

t for

a fe

lony

or

an a

ttem

pted

felo

ny?

Y

es

No

Are

you

or

is a

nyon

e liv

ing

with

you

in v

iola

tion

of p

roba

tion

or p

arol

e ac

cord

ing

to a

cou

rt?

Yes

N

o H

ave

you

or h

as a

nyon

e liv

ing

with

you

eve

r be

en d

isqu

alifi

ed fr

om r

ecei

ving

SN

AP

bec

ause

of f

rau

d or

inte

ntio

nal p

rogr

am v

iola

tion?

Yes

N

o

Are

you

or

is a

nyon

e in

you

r ho

useh

old

appl

ying

for

or r

ecei

ving

SN

AP

or

Tem

pora

ry A

ssis

tanc

e in

ano

ther

pla

ce?

Y

es

No

Are

you

or

is a

nyon

e liv

ing

with

you

blin

d, d

isab

led

or p

regn

ant?

Yes

No

If

Yes

, who

Are

you

or

is a

nyon

e liv

ing

with

you

a v

eter

an?

Y

es

No

If

Yes

, who

Do

you

or d

oes

anyo

ne li

ve in

a d

rug

or a

lcoh

ol tr

eatm

ent c

ente

r, S

tate

-cer

tifie

d gr

oup

livin

g fa

cilit

y or

Sta

te-c

ertif

ied

supe

rvis

ed/s

uppo

rtiv

e ap

artm

ent?

Y

es

No

If yo

u ar

e re

cert

ifyin

g fo

r S

NA

P, l

ist o

n th

e P

age

6 w

hat h

as c

hang

ed s

ince

you

r la

st a

pplic

atio

n or

rec

ertif

icat

ion

(suc

h as

mov

ed, h

ad

a ba

by, s

omeo

ne m

oved

in o

r ou

t of

you

r ho

useh

old)

. Y

ou

ma

y u

se

th

e p

ag

e 6

if

yo

u n

ee

d m

ore

ro

om

or

the

re is

oth

er

info

rma

tio

n t

ha

t y

ou

th

ink

we m

igh

t n

ee

d.

Go

to

Pa

ge

2

LDSS

-482

6 (R

ev.8

/12)

Pa

ge 2

IN

CO

ME

List

AL

L y

our i

ncom

e an

d th

e in

com

e of

any

one

livin

g w

ith y

ou. T

his

incl

udes

, but

is n

ot li

mite

d to

wag

es, i

ncom

e fr

om s

elf-e

mpl

oym

ent

(for e

xam

ple:

bab

ysitt

ing,

cle

anin

g, in

com

e fr

om a

room

er o

r boa

rder

) chi

ld s

uppo

rt, p

ensi

ons,

vet

eran

s be

nefit

s, d

isab

ility

, soc

ial

secu

rity

or S

SI, g

rant

for s

chol

arsh

ips

for r

ent o

r foo

d, T

empo

rary

Ass

ista

nce,

and

inco

me

from

frie

nds

or re

lativ

es.

Nam

e of

Per

son

Rec

eivi

ng In

com

e S

ourc

e of

Inco

me

H

ours

Wor

ked

Per

Mon

th

How

Ofte

n is

it R

ecei

ved?

(f

or

exa

mp

le,

we

ekly

, b

i-w

ee

kly

, m

on

thly

)

Gro

ss A

mou

nt R

ecei

ved

Bef

ore

Ded

uctio

ns

Do

you

or d

oes

anyo

ne li

ving

with

you

hav

e ch

ild/d

epen

dent

car

e co

sts

rela

ted

to e

mpl

oym

ent o

r tr

aini

ng?

Y

es

No

If Y

es, w

ho

.

A

mou

nt p

aid

$ __

____

____

__.

How

ofte

n pa

id (

e.g.

, wee

kly,

mon

thly

) __

____

____

____

____

____

___.

Hav

e yo

u or

has

any

one

livin

g w

ith y

ou c

hang

ed o

r qu

it jo

bs o

r re

duce

d an

y fo

rm o

f inc

ome

in th

e la

st 3

0 da

ys –

incl

udin

g re

duce

d w

ork

hour

s or

inco

me?

Y

es

No

Do

you

or d

oes

anyo

ne li

ving

with

you

hav

e an

y po

tent

ial i

ncom

e th

at h

as n

ot y

et b

een

rece

ived

?

Yes

No

If Y

es, e

xpla

in o

n P

age

6.

Do

you

or d

oes

anyo

ne li

ving

with

you

rec

eive

a P

erso

nal N

eeds

Allo

wan

ce (

PN

A)

or a

Mea

l Allo

wan

ce?

Y

es

No

If Y

es, w

ho

.

Hav

e yo

u or

has

any

one

in y

our

hous

ehol

d se

t asi

de a

ny in

com

e un

der

“PA

SS

: Pla

n T

o A

chie

ve S

elf S

uppo

rt”

appr

oved

by

the

Soc

ial S

ecur

ity A

dmin

istr

atio

n?

Yes

No

If Y

es, w

ho

.

Are

you

or

is a

nyon

e liv

ing

with

you

par

ticip

atin

g in

a s

trik

e?

Yes

No

If Y

es, w

ho

.

RE

SO

UR

CE

S

Res

ourc

es d

o no

t affe

ct th

e el

igib

ility

of m

ost h

ouse

hold

s ap

plyi

ng fo

r S

NA

P. H

owev

er, s

ome

reso

urce

info

rmat

ion

is u

sed

to d

eter

min

e if

you

qual

ify fo

r ex

pedi

ted

proc

essi

ng o

f you

r ap

plic

atio

n.

How

muc

h m

oney

doe

s ev

eryo

ne in

you

r ho

useh

old

have

? (F

or e

xam

ple,

on

your

per

son;

in y

our

hom

e, in

che

ckin

g an

d sa

ving

s ac

coun

ts, o

r ot

her

loca

tions

, inc

ludi

ng

join

tly h

eld

acco

unts

)

$_

____

____

____

_ B

elon

gs to

.

Oth

er fi

nanc

ial a

sset

s? (

For

exa

mpl

e, s

tock

s, b

onds

, ret

irem

ent a

ccou

nts,

sav

ings

bon

ds, m

utua

l fun

ds, I

RA

s, tr

ust f

unds

, mon

ey m

arke

t cer

tific

ates

)

Yes

N

o

If

Yes

, am

ount

$__

____

____

____

_ T

ype

____

____

____

____

____

____

____

____

Ow

ner

____

____

____

____

____

____

____

____

_.

How

man

y ca

rs, t

ruck

s or

oth

er v

ehic

les

do y

ou o

r an

yone

in y

our

hous

ehol

d ha

ve?

___

#1

Yea

r __

___

Mak

e __

____

____

____

____

____

_ M

odel

___

____

____

____

____

____

_ O

wne

r __

____

____

____

____

____

___

___

#2

Yea

r __

___

Mak

e __

____

____

____

____

____

_ M

odel

___

____

____

____

____

____

_ O

wne

r __

____

____

____

____

____

___

Do

you

or a

nyon

e ap

plyi

ng o

wn

any

prop

erty

incl

udin

g yo

ur o

wn

hom

e?

Yes

No

if y

es, l

ist p

rope

rty_

____

____

____

____

____

____

Ow

ner

____

____

____

____

____

Has

any

one

appl

ying

sol

d, g

iven

aw

ay o

r tr

ansf

erre

d ca

sh o

r pr

oper

ty in

the

last

thre

e m

onth

s to

qua

lify

for

SN

AP

?

Yes

No

LIV

ING

AR

RA

NG

EM

EN

TS

AN

D E

XP

EN

SE

S

Che

ck a

ll th

e de

scrip

tions

that

app

ly to

you

r ho

useh

old:

O

wn

hom

e or

pay

ing

for

hom

e

Ren

ting

M

igra

nt/s

easo

nal f

arm

wor

ker

N

o pe

rman

ent r

esid

ence

Liv

e w

ith r

elat

ives

or

frie

nds

List

exp

ense

s:

Mon

thly

ren

t or

mor

tgag

e pa

ymen

t $ _

____

____

____

Tax

on

hom

e pe

r ye

ar $

___

____

____

_ In

sura

nce

on h

ome

per

year

$ _

____

____

____

.

Pay

sep

arat

ely

for

Hea

t?

Yes

No

If y

es, s

peci

fy ty

pe o

f hea

ting:

G

as

Ele

ctric

O

il

Woo

d

Coa

l

Pro

pane

O

ther

(lis

t) _

____

____

____

____

H

eat C

o. N

ame

____

____

____

____

____

____

___

H

eat C

o. A

cct.

No.

___

____

____

____

____

____

____

___

Yo

u m

ay u

se

th

e p

ag

e 6

if

yo

u n

ee

d m

ore

ro

om

or

the

re is

oth

er

info

rma

tio

n t

ha

t y

ou

th

ink

we m

igh

t n

ee

d.

Go

to

Pa

ge

3

LDSS

-482

6 (R

ev.8

/12)

Pa

ge 3

LIV

ING

AR

RA

NG

EM

EN

TS

AN

D E

XP

EN

SE

S (

Co

nt’

d)

Pay

for

air

cond

ition

ing,

eith

er in

you

r el

ectr

ic b

ill o

r as

a s

epar

ate

fee?

Y

es

No

Pay

sep

arat

ely

for

utili

ties

(oth

er th

an h

eatin

g/co

olin

g)?

Y

es

No

(for

exa

mpl

e, li

ghts

, coo

king

gas

, was

her/

drye

r fe

es, g

arba

ge/tr

ash,

wat

er, i

nitia

l ins

talla

tion

of u

tiliti

es).

Doe

s an

yone

els

e pa

y an

y of

thes

e ex

pens

es fo

r yo

u (s

ome

exam

ples

are

Sec

tion

8 or

oth

er s

ubsi

dy p

rogr

am)?

Yes

N

o I

f yes

, who

pay

s w

hat?

___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

_ .

Do

you

or d

oes

anyo

ne li

ving

with

you

pay

cou

rt-o

rder

ed c

hild

sup

port

?

Yes

No

If y

es, w

ho _

____

____

____

____

____

____

____

____

____

N

ame(

s) o

f chi

ld(r

en)

supp

ort i

s be

ing

paid

for

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

____

____

____

___

P

aym

ent a

mou

nt $

____

____

____

___

Fre

quen

cy o

f pay

men

ts (

for

exam

ple,

wee

kly,

bi-w

eekl

y, m

onth

ly)

____

____

____

___

Are

you

, and

/or

anyo

ne li

ving

with

you

, blin

d/di

sabl

ed o

r at

leas

t age

60?

If s

o, d

oes

such

per

son

have

med

ical

bill

s?

Yes

N

o I

f yes

, lis

t on

the

page

6 w

hat t

hey

are

for,

how

muc

h an

d w

ho is

res

pons

ible

for

paym

ent.

Are

you

, and

/or

anyo

ne li

ving

with

you

, on

Med

icai

d w

ith a

spe

ndow

n?

Yes

N

o If

yes

, who

___

____

____

____

____

____

___

Am

ount

$ _

____

____

____

____

____

Are

you

, and

/or

anyo

ne li

ving

with

you

(16

yea

rs o

ld o

r ol

der)

enr

olle

d in

sch

ool o

r tr

aini

ng?

Y

es

No

If y

es, w

ho _

____

____

____

____

_ w

here

___

____

____

____

__

Yo

u m

ay u

se

th

e p

ag

e 6

if

yo

u n

ee

d m

ore

ro

om

or

the

re is

oth

er

info

rma

tio

n t

ha

t y

ou

th

ink

we m

igh

t n

ee

d.

REA

D T

HE

IMPO

RTA

NT

INFO

RM

ATI

ON

BEL

OW

SN

AP P

ENAL

TY W

AR

NIN

G –

Any

info

rmat

ion

you

prov

ide

in c

onne

ctio

n w

ith y

our

appl

icat

ion

for

SNAP

will

be

subj

ect t

o ve

rific

atio

n by

Fed

eral

, Sta

te a

nd

loca

l offi

cial

s. If

any

info

rmat

ion

is in

corre

ct, y

ou m

ay b

e de

nied

SN

AP

. You

may

be

subj

ect t

o cr

imin

al p

rose

cutio

n fo

r kno

win

gly

prov

idin

g in

corre

ct in

form

atio

n.

You

will

nev

er b

e ab

le to

get

SN

AP

aga

in if

you

are

foun

d gu

ilty

in a

cou

rt of

law

for t

he s

econ

d tim

e of

buy

ing

or s

ellin

g co

ntro

lled

subs

tanc

es (i

llega

l dru

gs o

r ce

rta

in d

rugs f

or

whic

h a

do

cto

r’s p

rescrip

tio

n i

s r

eq

uir

ed)

in e

xcha

nge

for S

NAP

; or

foun

d gu

ilty

in a

cou

rt of

law

of s

ellin

g or

get

ting

firea

rms,

am

mun

ition

or

expl

osiv

es in

exc

hang

e fo

r SN

AP

; or

foun

d gu

ilty

in a

cou

rt of

traf

ficki

ng in

SN

AP w

orth

$50

0 or

mor

e. T

raffi

ckin

g in

clud

es th

e ille

gal u

se, t

rans

fer,

acqu

isiti

on,

alte

ratio

n or

pos

sess

ion

of S

NA

P, a

utho

rizat

ion

card

s or

acc

ess

devi

ces;

or f

ound

gui

lty o

f com

mitt

ing

a th

ird In

tent

iona

l Pro

gram

Vio

latio

n (IP

V).

You

will

not

be

able

to g

et S

NAP

for t

wo

year

s if

you

are

foun

d gu

ilty

in a

cou

rt of

law

for t

he fi

rst t

ime

of b

uyin

g or

sel

ling

cont

rolle

d su

bsta

nces

(ille

gal d

rugs

or

ce

rta

in d

rug

s fo

r w

hic

h a

do

cto

r’s p

rescrip

tio

n is r

equ

ire

d)

in e

xch

ang

e fo

r SN

AP

.

If yo

u ha

ve c

omm

itted

you

r:

Firs

t IP

V, y

ou w

ill n

ot b

e ab

le to

get

SN

AP fo

r one

yea

r.

Sec

ond

IPV

, you

will

not

be

able

to g

et S

NAP

for t

wo

year

s.

A c

ourt

coul

d al

so b

ar y

ou fr

om re

ceiv

ing

SNAP

for a

n ad

ditio

nal 1

8 m

onth

s. If

you

mak

e a

fals

e st

atem

ent a

bout

who

you

are

or w

here

you

live

in o

rder

to g

et

mul

tiple

SN

AP b

enef

its, y

ou w

ill n

ot b

e ab

le to

get

SN

AP fo

r ten

yea

rs (o

r per

man

ently

if th

is is

the

third

IPV

).

You

may

be

foun

d gu

ilty

of a

n IP

V if

you

mak

e a

fals

e or

mis

lead

ing

stat

emen

t, or

mis

repr

esen

t, co

ncea

l or w

ithho

ld fa

cts;

or

com

mit

any

act t

hat c

onst

itute

s a

viol

atio

n of

Fed

eral

or S

tate

law

for t

he p

urpo

se o

f usi

ng, p

rese

ntin

g, tr

ansf

errin

g, a

cqui

ring,

rece

ivin

g, p

osse

ssin

g or

traf

ficki

ng o

f SN

AP

ben

efits

, aut

horiz

atio

n ca

rds

or re

usab

le d

ocum

ents

use

d as

par

t of t

he E

lect

roni

c B

enef

it Tr

ansf

er (E

BT)

sys

tem

.

You

coul

d al

so b

e fin

ed u

p to

$25

0,00

0, s

ent t

o ja

il fo

r up

to 2

0 ye

ars,

or b

oth.

A

nyon

e w

ho is

flee

ing

to a

void

pro

secu

tion,

cus

tody

or c

onfin

emen

t for

a fe

lony

, or w

ho is

vio

latin

g a

cond

ition

of p

roba

tion

or p

arol

e, is

not

elig

ible

to re

ceiv

e S

NAP

. If

you

get

mor

e SN

AP b

enef

its t

han

you

shou

ld h

ave

(ove

rpay

men

t), y

ou m

ust

pay

them

bac

k. I

f yo

ur c

ase

is a

ctiv

e, w

e w

ill t

ake

back

the

am

ount

of

the

over

paym

ent f

rom

futu

re S

NAP

ben

efits

that

you

get

. If y

our c

ase

is c

lose

d, y

ou m

ay p

ay b

ack

the

over

paym

ent t

hrou

gh a

ny u

nuse

d S

NAP

ben

efits

rem

aini

ng

in y

our a

ccou

nt, o

r you

may

pay

cas

h.

LDSS

-482

6 (R

ev.8

/12)

Pa

ge 4

R

EAD

TH

E IM

POR

TAN

T IN

FOR

MA

TIO

N B

ELO

W (c

ont’d)

If yo

u ha

ve a

n ov

erpa

ymen

t tha

t is

not p

aid

back

, it w

ill b

e re

ferre

d fo

r col

lect

ion

in a

num

ber o

f way

s, in

clud

ing

auto

mat

ed c

olle

ctio

n by

the

fede

ral g

over

nmen

t. Fe

dera

l ben

efits

(su

ch a

s S

ocia

l Sec

urity

) an

d ta

x re

fund

s th

at y

ou a

re e

ntitl

ed to

rec

eive

may

be

take

n to

pay

bac

k th

e ov

erpa

ymen

t. Th

e de

bt w

ill al

so b

e su

bjec

t to

proc

essi

ng c

harg

es.

Any

exp

unge

d SN

AP b

enef

its w

ill b

e pu

t tow

ards

you

r ove

rpay

men

t. If

you

appl

y fo

r SN

AP

agai

n, a

nd h

ave

not r

epai

d th

e am

ount

you

ow

e, y

our S

NA

P be

nefit

s w

ill b

e re

duce

d if

you

begi

n to

get

them

aga

in. Y

ou w

ill b

e no

tifie

d, a

t tha

t tim

e, o

f the

am

ount

of r

educ

ed b

enef

its y

ou w

ill g

et.

CO

NSE

NT

– I

unde

rsta

nd th

at b

y si

gnin

g th

is a

pplic

atio

n fo

rm I

agre

e to

any

inve

stig

atio

n m

ade

by th

e N

ew Y

ork

Sta

te O

ffice

of

Tem

pora

ry a

nd D

isab

ility

A

ssis

tanc

e or

my

loca

l soc

ial s

ervi

ces

dist

rict t

o ve

rify

or c

onfir

m th

e in

form

atio

n I h

ave

give

n or

any

oth

er in

vest

igat

ion

mad

e by

them

in c

onne

ctio

n w

ith m

y re

ques

t fo

r SN

AP.

If ad

ditio

nal i

nfor

mat

ion

is r

eque

sted

, I

will

pro

vide

it.

I w

ill a

lso

coop

erat

e w

ith S

tate

and

Fed

eral

per

sonn

el in

a S

NAP

Qua

lity

Con

trol

Rev

iew

.

CO

NSE

NT

FOR

REL

EASE

OF

CO

NFI

DEN

TIA

L U

NEM

PLO

YMEN

T IN

SUR

ANC

E (U

I) IN

FOR

MAT

ION

– I

auth

oriz

e th

e N

ew Y

ork

Sta

te D

epar

tmen

t of L

abor

(D

OL)

to re

leas

e an

y co

nfid

entia

l inf

orm

atio

n, m

aint

aine

d by

DO

L fo

r U

nem

ploy

men

t Ins

uran

ce (U

I) pu

rpos

es, t

o th

e N

ew Y

ork

Sta

te O

ffice

of T

empo

rary

and

D

isab

ility

Ass

ista

nce

(OTD

A).

This

inf

orm

atio

n in

clud

es U

I be

nefit

cla

ims

and

wag

e re

cord

s. I

und

erst

and

that

OTD

A,

alon

g w

ith S

tate

and

loc

al a

genc

y em

ploy

ees

wor

king

in lo

cal s

ocia

l ser

vice

s di

stric

t offi

ces,

will

use

the

UI i

nfor

mat

ion

for e

stab

lishi

ng o

r ver

ifyin

g el

igib

ility

for,

and

the

amou

nt o

f, TA

, MA

, or F

S be

nefit

s ap

plie

d fo

r in

this

app

licat

ion

and

for i

nves

tigat

ions

to d

eter

min

e w

heth

er I

rece

ived

ben

efits

to w

hich

I w

as n

ot e

ntitl

ed.

SUA

(STA

ND

ARD

UTI

LITY

ALL

OW

AN

CE)

IN

FOR

MAT

ION

– I

und

erst

and

that

SN

AP r

ecip

ient

s ar

e ca

tego

rical

ly i

ncom

e el

igib

le f

or t

he H

ome

Ener

gy

Ass

ista

nce

Pro

gram

(HEA

P).

If I a

m n

ot in

clud

ed in

the

annu

al a

utom

atic

HE

AP p

aym

ent p

roce

ss fo

r cer

tain

SN

AP r

ecip

ient

s, m

y ho

useh

old

inte

nds

to a

pply

fo

r a H

EAP

ben

efit

with

in th

e ne

xt 1

2 m

onth

s. If

I de

cide

not

to a

pply

for H

EAP

with

in th

e ne

xt 1

2 m

onth

s, I

will

let m

y w

orke

r kno

w.

TELE

PHO

NE

ALL

OW

ANC

E IN

FOR

MA

TIO

N –

I un

ders

tand

that

SN

AP

reci

pien

ts a

re e

ligib

le fo

r a te

leph

one

allo

wan

ce if

they

pay

to u

se a

hom

e ph

one,

cel

l ph

one,

pho

ne, p

hone

cal

ling

card

or c

oin

oper

ated

pay

pho

ne. I

f I d

o no

t hav

e an

y co

st to

mak

e ph

one

calls

, I w

ill le

t my

wor

ker k

now

.

CH

ANG

ES –

I ag

ree

to in

form

the

agen

cy p

rom

ptly

of a

ny c

hang

e in

my

need

s, in

com

e, p

rope

rty, l

ivin

g ar

rang

emen

t, pr

egna

ncy

stat

us o

r add

ress

to th

e be

st

of m

y kn

owle

dge

or b

elie

f in

acco

rdan

ce w

ith m

y re

porti

ng re

quire

men

ts.

REQ

UIR

EMEN

T TO

REP

OR

T/VE

RIF

Y H

OU

SEH

OLD

EXP

ENSE

S –

I un

ders

tand

that

my

hous

ehol

d m

ust r

epor

t chi

ld c

are

and

utili

ty e

xpen

ses

in o

rder

to g

et

a SN

AP d

educ

tion

for

thes

e ex

pens

es.

I fu

rther

und

erst

and

that

my

hous

ehol

d m

ust

repo

rt an

d ve

rify

rent

/mor

tgag

e pa

ymen

ts,

prop

erty

tax

es,

insu

ranc

e,

med

ical

exp

ense

s an

d ch

ild s

uppo

rt pa

id t

o a

non-

hous

ehol

d m

embe

r in

ord

er t

o ge

t a

SNAP

ded

uctio

n fo

r th

ese

expe

nses

. I

unde

rsta

nd t

hat

failu

re t

o re

port/

verif

y th

e ab

ove

expe

nses

will

be

seen

as

a st

atem

ent b

y m

y ho

useh

old

that

I/w

e do

not

wan

t to

rece

ive

a de

duct

ion

for

thos

e un

repo

rted/

unve

rifie

d ex

pens

es. A

ded

uctio

n fo

r th

ese

expe

nses

may

mak

e m

e el

igib

le f

or S

NA

P or

may

incr

ease

my

SNA

P be

nefit

s. I

und

erst

and

that

I m

ay r

epor

t/ver

ify t

hese

ex

pens

es a

t any

tim

e in

the

futu

re. T

his

dedu

ctio

n w

ould

then

be

appl

ied

to th

e ca

lcul

atio

n of

SN

AP in

futu

re m

onth

s in

acc

orda

nce

with

the

rule

s fo

r ch

ange

re

porti

ng a

nd p

roce

ssin

g ch

ange

s.

PRIV

ACY

AC

T ST

ATE

MEN

T –

CO

LLEC

TIO

N A

ND

USE

OF

SOC

IAL

SEC

UR

ITY

NU

MB

ER (S

SN) –

Th

e c

olle

ctio

n o

f S

SN

’s is a

uth

orize

d f

or

ea

ch

ho

use

hold

m

embe

r w

ith r

espe

ct t

o S

NAP

pur

suan

t to

the

Foo

d S

tam

p Ac

t of

197

7 (a

s am

ende

d, 7

US

Cod

e 20

11-2

036)

. Th

e in

form

atio

n w

e co

llect

will

be

used

to

dete

rmin

e w

heth

er y

our

hous

ehol

d is

elig

ible

or

cont

inue

s to

be

elig

ible

for b

enef

its. W

e w

ill v

erify

this

info

rmat

ion

thro

ugh

com

pute

r mat

chin

g pr

ogra

ms.

Thi

s in

form

atio

n w

ill a

lso

be u

sed

to m

onito

r co

mpl

ianc

e w

ith p

rogr

am r

egul

atio

ns a

nd fo

r pr

ogra

m m

anag

emen

t. Th

e in

form

atio

n w

ill b

e us

ed to

che

ck id

entit

y, to

ve

rify

earn

ed a

nd u

near

ned

inco

me,

and

to d

eter

min

e if

appl

ican

ts o

r rec

ipie

nts

can

rece

ive

mon

ey o

r oth

er h

elp.

The

info

rmat

ion

may

be

disc

lose

d to

Sta

te a

nd

Fede

ral a

genc

ies

for o

ffici

al e

xam

inat

ion

and

to la

w e

nfor

cem

ent o

ffici

als

for t

he p

urpo

se o

f app

rehe

ndin

g pe

rson

s fle

eing

to a

void

the

law

.

If yo

u or

any

one

appl

ying

/rece

rtify

ing

does

not

hav

e an

SSN

, a S

SN m

ust b

e ap

plie

d fo

r at t

he S

ocia

l Sec

urity

Age

ncy.

LDSS

-482

6 (R

ev.8

/12)

Pa

ge 5

R

EAD

TH

E IM

POR

TAN

T IN

FOR

MAT

ION

BEL

OW

(cont’d)

CIT

IZEN

SHIP

/IMM

IGR

ATIO

N S

TATU

S– I

sw

ear

and/

or a

ffirm

und

er p

enal

ty o

f pe

rjury

tha

t th

e in

form

atio

n I

have

pro

vide

d ab

out

the

citiz

ensh

ip a

nd

imm

igra

tion

stat

us o

f m

y se

lf an

d ev

eryo

ne li

ving

with

me

is t

rue

and

corre

ct.

I un

ders

tand

tha

t an

y in

form

atio

n I p

rovi

de t

o ve

rify

the

imm

igra

tion

stat

us o

f an

yone

app

lyin

g fo

r SN

AP m

ay b

e ch

ecke

d fo

r aut

hent

icity

with

the

Uni

ted

Stat

es C

itize

nshi

p an

d Im

mig

ratio

n Se

rvic

es.

Fo

r S

NA

P, c

itize

nshi

p m

ust b

e do

cum

ente

d on

ly if

que

stio

nabl

e.

NO

N-D

ISC

RIM

INAT

ION

NO

TIC

E –

In

acco

rdan

ce w

ith F

eder

al L

aw a

nd U

.S.

Dep

artm

ent

of A

gric

ultu

re (

USD

A)

polic

y, t

his

inst

itutio

n is

pro

hibi

ted

from

di

scrim

inat

ing

on th

e ba

sis

of ra

ce, c

olor

, nat

iona

l orig

in, s

ex, a

ge, r

elig

ion,

pol

itica

l bel

ief,

or d

isab

ility

. To

file

a co

mpl

aint

of d

iscr

imin

atio

n w

rite

US

DA

, Dire

ctor

, O

ffice

of

Civ

il R

ight

s, R

oom

326

-W, W

hitte

n B

uild

ing,

140

0 In

depe

nden

ce A

venu

e, S

.W.,

Was

hing

ton,

D.C

. 20

250-

9410

or

call

(202

) 72

0-59

64 (

voic

e an

d TD

D).

USD

A is

an

equa

l opp

ortu

nity

pro

vide

r and

em

ploy

er.

LIFE

LIN

E: F

or a

pplic

ants

/reci

pien

ts o

f SN

AP:

Th

e O

ffice

of T

empo

rary

and

Dis

abili

ty A

ssis

tanc

e m

ay o

r m

ay n

ot r

elea

se y

our

nam

e an

d ad

dres

s to

you

r te

leph

one

serv

ice

prov

ider

. You

r tel

epho

ne s

ervi

ce p

rovi

der m

ay o

r may

not

use

this

info

rmat

ion

to e

nrol

l you

in th

eir L

ifelin

e S

ervi

ce fo

r a d

isco

unte

d te

leph

one

rate

.

If

you

do

no

t wan

t thi

s in

form

atio

n re

leas

ed, c

heck

this

box

You

may

con

tact

you

r tel

epho

ne s

ervi

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LDSS

-482

6 (R

ev.8

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Pa

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this

are

a f

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addit

ional

info

rmati

on:

Who

: _______________

_________________________E

xpla

nati

on:

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: _______________

_________________________E

xpla

nati

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: _______________

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any

tim

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SIG

NA

TUR

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DA

TE

For

Agen

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se O

nly

Elig

ibilit

y D

eter

min

ed b

y __

____

____

____

____

____

____

____

____

____

____

____

____

____

____

__

Dat

e __

____

____

____

____

_

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natu

re o

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aine

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___

____

____

____

____

____

____

____

____

____

_ D

ate

____

____

____

___

Em

ploy

ed b

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Soc

ial S

ervi

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Dis

trict

Pro

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(Spec

ify)

__________

__

________________

__________________________________________________________

Rea

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____

_/__

___/

____

__

With

draw

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____

____

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____

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____

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___

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IN

-PER

SON

INTE

RVI

EW

T

ELEP

HO

NE

INTE

RVI

EW

Com

men

ts:

1

2

Will you be 18 years old on or before election day? Yes □ No □

If you answered NO, do not complete this form unless you will be 18 by the end of the year.

For Board use only!

3

4

5 Address where you get your mail (if different from above) P.O. Box, star route, etc. Post Office Zip Code

6 Date of Birth

7 Sex (circle)

M F

8 Home Tel. Number (optional)

The last year you voted Your Address was (give house number, street and city)

In county/state Under the Name (if different from your name now)

NYS Agency-Based Voter Registration Form

(If you check yes, please complete VOTER REGISTRATION APPLICATION at bottom of page)

“If you are not registered to vote where you live now, would you like to apply to register here today?”

□ YES

□ NO because I choose not to register OR

□ I am already registered at my current address OR

□ I asked for and received a mail registration form.

If you do not check any box, you will be considered to have

decided not to register to vote at this time.

_____/______/______

(Signature) (Date)

(Please Print Name)

Important! Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Información en español: si le interesa obtener este formulario en español, llame al 1-800-367-8683

□ Yes, I need an application for an Absentee Ballot Please print or type in blue or black ink □ Yes, I would like to be an Election Day worker

9

ID Number—Check the applicable box and provide your number:

□ New York DMV number __ __ __ __ __ __ __ __ __ If you do not have a New York DMV number, please provide:

□ Last four digits of your Social Security Number __ __ __ __ □ I do not have a New York Driver’s license number

12

AFFIDAVIT: I swear or affirm that I am a citizen of the United States. I will have lived in the county, city or village for at least 30 days before the election. I will meet all requirements to register to vote in New York State. This is my signature or mark on the line below. The above information is true, I understand that if it is not true, I can be convicted and fined up to $5,000 and/or jailed for up to four years.

(Signature or Mark in Ink) (Date)

→

NVRA-05 (01/2011) VOTER REGISTRATION APPLICATION (instructions on back)

(Optional) Register to donate your organs and tissues Last Name First Name Middle Initial Suffix Address Apt Number Zip Code City Birth Date Sex □ M □ F Eye Color Height Ft. In.

By signing below, you certify that you are:

18 years of age or older

Consent to donate all of your organs and

tissues for transplantation, research, or both;

Authorizing the Board of Elections to provide your name and identifying

information to DOH for enrollment in the Registry;

And authorizing DOH to allow access to this information to federally

regulated organ procurement organizations and NYS-licensed tissue and eye banks and hospitals upon your death.

Sign Date

11

Choose a party -- Check one box only □ Democratic Party □ Republican Party □ Conservative Party □ Working Families Party □ Independence Party □ Green Party □ Other (write in)

□ I do not wish to enroll in a party

Are you a U. S. citizen?

Yes □ No □

If you answered NO, do not complete this form.

Last Name First Name Middle Initial Suffix

Address where you live (do not give P.O. address) Apt. No. City/Town/Village Zip Code County

10

Qualifications for Registration You Can Use This Form To:

register to vote in New York State; change your name and/or address, if there is a change since you last voted; enroll in a political party or change your enrollment.

To Register You Must: be a U.S. citizen; be 18 years old by December 31 of the year in which you file this form (note: You must be 18 years old by the date of the general, primary, or other election in which you want to vote.); be a resident of the County, or of the City of New York at least 30 days before an election; not be in jail or on parole for a felony conviction; and not claim the right to vote elsewhere.

Important! If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:

New York State Board of Elections, 40 Steuben Street, Albany, New York 12207-2109 Telephone: 1-800-469-6872;

TDD/TTY users contact the New York State Relay at 711; or visit our web site - www.elections.state.ny.us

Your decision to register will remain confidential and will be used only for voter registration purposes. Anyone not choosing to register to vote and/or information regarding the office to which the application was submitted will remain confidential, to be used only for voter regis-tration purposes.

Verifying your identity We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID number), or the last four digits of your social security number, which you will fill in Box 9. If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement, pay-check, government check or some other government document that shows your name and address. You may include a copy of one of those types of ID with this form. If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.

To complete this form:

It is a crime to procure a false registration or to furnish false information to the Board of Elections.

Box 9: You must make one selection. For questions refer to Verifying your identity above.

Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?). If you voted before under a different name, put down that name. If not, write “Same”.

Box 11: Check one box only. To vote in a primary election, you must be enrolled in one of these listed parties — Except the Independence Party, which permits non-enrolled voters to participate in certain primary elections.

Appendix E –

SNAP Application

Expedited Processing Summary Sheet

(LDSS-3938)

LDSS-3938 NYC (Rev. 9/14) NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE DATE

APPLICATION FILED

MONTH DAY YEAR

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

APPLICATION EXPEDITED PROCESSING SUMMARY SHEET

CASE NAME CASE NUMBER SCREENED BY DATE OF

SCREENING

MONTH DAY YEAR

INSTRUCTIONS FOR COMPLETING THIS FORM

1. Screen all applicants for expedited application processing and Working Families Supplemental Nutrition Program Initiative (WFSNAPI), on the day of application.

2. State results of screening in Part Four; and if qualified for expedited application processing, conduct a Full Eligibility Interview and complete Part Five within five calendar days of application.

3. If Full Eligibility Interview determines Household eligible for SNAP benefits:

Make benefits available to client within five calendar days after the date of application.

Send/Provide client with the CNS “Approval Notice” or manual “Action Taken Notice” within five calendar days after the application date.

Follow-up on all pended verification before issuance of on-going benefits beyond the initial expedited issuance period.

PART ONE – CHECK YES OR NO

IS THE HOUSEHOLD ALREADY RECEIVING SNAP BENEFITS THIS MONTH?

NOTE: IF “YES” IS CHECKED, BUT HOUSEHOLD ENTERED A DOMESTIC VIOLENCE SHELTER DURING THE MONTH OF APPLICATION, CONTINUE WITH PART TWO.

YES - IF YES, HOUSEHOLD DOES

NOT QUALIFY FOR EXPEDITED PROCESSING COMPLETE PART FOUR

NO - IF NO, CONTINUE

WITH PART TWO

PART TWO – CHECK YES OR NO

** In determining GROSS INCOME, exclude non-countable income such as child support payments made to a person outside the household.

SECTION

A

CHECK YES OR NO

DOES THE HOUSEHOLD HAVE $100 OR LESS IN CASH, SAVINGS OR OTHER LIQUID RESOURCES, AND

YES – IF YES, HOUSEHOLD

QUALIFIES FOR EXPEDITED PROCESSING.

COMPLETE PART FOUR

NO – IF NO, CONTINUE

WITH SECTION B.

HAS THE HOUSEHOLD RECEIVED OR DOES IT EXPECT TO

RECEIVE LESS THAN $150 GROSS INCOME ** DURING THE

MONTH OF APPLICATION?

SECTION

B

ARE HOUSEHOLD’S TOTAL GROSS INCOME ** DURING MONTH OF APPLICATION PLUS THE HOUSEHOLD’S LIQUID RESOURCES LESS THAN THEIR MONTHLY RENT/MORTGAGE PLUS UTILITY EXPENSES?

YES

IF YES, HOUSEHOLD QUALIFIES FOR EXPEDITED PROCESSING. COMPLETE PART FOUR

NO

IF NO, HOUSEHOLD DOES NOT QUALIFY FOR EXPEDITED PROCESSING UNLESS QUALIFIED UNDER PART THREE.

GO TO PART THREE IF A MIGRANT/SEASONAL FARMWORKER OTHERWISE, COMPLETE PART FOUR

Rent/Mortgage: $ _____________ Income: $_____________

*Heat/AC: ______________Resources: ____________

*Utilities: ______________

*Telephone: ______________

*Homeless Shelter Deduction _______________

Total Expenses: $ ______________ Totals: _____________

* Use HT/AC Standard Utility Allowance (SUA) only if household incurs costs or received HEAP greater than $20 during the month of application or within the previous 12 months of application. ** Use the Homeless Shelter Deduction for “undomiciled” households who do no reside in a homeless shelter.

PART THREE – MIGRANT/SEASONAL FARM WORKER HOUSEHOLDS ONLY - CHECK YES OR NO

A. IS THIS A HOUSEHOLD WITH NO MORE THAN $100 IN LIQUID RESOURCES?

AND

YES NO – IF NO, HOUSEHOLD DOES NOT QUALIFY

FOR EXPEDITED PROCESSING. COMPLETE PART FOUR

B. THE ONLY INCOME FOR THE MONTH OF APPLICATION:

(1) WAS TERMINATED BEFORE APPLICATION?

OR

(2) IS NEW, AND NO MORE THAN $25 GROSS INCOME WILL BE RECEIVED WITHIN TEN DAYS AFTER APPLICATION

YES

YES

NO CONTINUE WITH B2

NO

IF YES TO QUESTION A, AND YES TO EITHER QUESTION B1 OR QUESTION B2, HOUSEHOLD QUALIFIES FOR EXPEDITED PROCESSING,

IF NO TO BOTH B1 & B2 HH DOES NOT QUALIFY, COMPLETE PART FOUR IN EITHER SITUATION

LDSS-3938 NYC (Rev. 9/14)

PART FOUR - RESULTS OF EVALUATION FOR EXPEDITED APPLICATION PROCESSING - CHECK ONE

QUALIFIED FOR EXPEDITED APPLICATION PROCESSING. NOT QUALIFIED FOR

EXPEDITED APPLICATION PROCESSING STOP HERE

NOT ENOUGH INFORMATION IS PROVIDED ON

THE APPLICATION TO DETERMINE IF ELIGIBLE FOR EXPEDITED PROCESSING.

NOTES:

PART FIVE - ELIGIBILITY INTERVIEW – COMPLETE SECTIONS A, B AND C

VERIFICATION - CHECK YES OR NO

SECTION A

1. CAN APPLICANT’S IDENTITY BE VERIFIED?

IF DOCUMENTARY EVIDENCE IS NOT READILY AVAILABLE, COLLATERAL CONTACTS ARE ACCEPTABLE. NO SPECIFIC DOCUMENT CAN BE REQUIRED.

YES, IF ELIGIBLE

BENEFITS CAN BE ISSUED PROVIDED ANY OUTSTANDING REQUIREMENTS HAVE BEEN MET GO TO QUESTION 2

NO

IF APPLICANT IS DEEMED ELIGIBLE, SNAP BENEFITS CANNOT BE ISSUED UNTIL VERIFICATION OF IDENTITY IS PROVIDED GO TO QUESTION 2

2. WAS THE HOUSEHOLD’S LAST ISSUANCE AN EXPEDITED ISSUANCE?

YES

GO TO QUESTION 3

NO

IF DEEMED ELIGIBLE, HH CAN RECEIVE BENEFITS WITH ALL OTHER VERIFICATION PENDED, CONTINUE TO SECTION B

3. IF YES TO QUESTION 2, HAS ALL RELEVANT VERIFICATION BEEN SUBMITTED?

YES

IF DEEMED ELIGIBLE HH CAN RECEIVE BENEFITS WITH ALL OTHER VERIFICATION PENDED, CONTINUE TO SECTION B

NO

If HH IS DEEMED ELIGIBLE, SNAP BENEFITS CANNOT BE ISSUED UNTIL ELIGIBILITY IS VERIFIED. ALLOW 10 DAYS FOR VERIFICATION TO BE SUBMITTED. DATE REQUESTED: _____________ DATE SUBMITTED: _____________

SECTION B

DATE OF ELIGIBILITY INTERVIEW: WORKER NAME:

PLEASE COMPLETE FOR NON-CA SNAP HOUSEHOLDS ONLY

1. IS ANY ADULT* (18 YEARS OF AGE OR OLDER) MEMBER OF YOUR HOUSEHOLD EITHER WORKING 30 OR MORE HOURS PER WEEK OR EARNING $217.50 OR MORE PER WEEK?

OR

YES

IF YES, HOUSEHOLD PRESUMPTIVELY QUALIFIES FOR WFSNAPI.

NO

IF NO GO TO QUESTION 2.

2. ARE ANY TWO (2) ADULT* MEMBERS OF YOUR HOUSEHOLD EACH EITHER WORKING 20 OR MORE HOURS PER WEEK OR EARNING $145 OR MORE PER WEEK?

* (Also Minor Heads of SNAP Household)

YES

IF YES, HOUSEHOLD PRESUMPTIVELY QUALIFIES FOR WFSNAPI.

NO

IF NO, HOUSEHOLD DOES NOT QUALIFY FOR WFSNAPI.

AGENCY DISPOSITION OF SNAP BENEFIT ELIGIBILITY - CHECK APPROPRIATE BOXES

SECTION

C

COMPLETION OF THIS SECTION IS OPTIONAL – DISTRICT DISCRETION

ELIGIBLE

ELIGIBLE (Applied on or before 15th of month; zero benefit due to proration)

ELIGIBLE (Applied after 15th of month; zero first month’s benefit due to proration; full second month’s benefit)

ELIGIBLE (Applied after 15th of month; prorated first month’s benefit plus second month’s benefit)

INELIGIBLE: Indicate reason:

HOUSEHOLD IS INELIGIBLE FOR THE PROGRAM DUE TO PROGRAM RULES (provide explanation in comments.)

VERIFICATION OF IDENTITY NOT PROVIDED (SEE A1 ABOVE)

HH DID NOT SUBMIT ALL REQUIRED NON-IDENTITY VERIFICATION (SEE A3 ABOVE)

Other Denial Reason/Comments __________________________________________________________________________________________

DATE OF FINAL DISPOSITION ON SNAP BENEFIT ELIGIBILITY:

WORKER NAME:

LDSS-3938 (Rev. 9/14)

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

DATE APPLICATION

FILED

MONTH DAY YEAR

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) APPLICATION EXPEDITED PROCESSING SUMMARY SHEET

CASE NAME CASE NUMBER SCREENED BY DATE OF

SCREENING

MONTH DAY YEAR

INSTRUCTIONS FOR COMPLETING THIS FORM

1. Screen all applicants for expedited application processing Working Families SNAP Initiative (WFSNAPI), on the day of application.

2. State results of screening in Part Four; and if qualified for expedited application processing, conduct a Full Eligibility Interview and complete Part Five within five calendar days of application.

3. If Full Eligibility Interview determines Household eligible for SNAP benefits:

Make benefits available to client within five calendar days after the date of application

Send/Provide client with the CNS “Approval Notice” or manual “Action Taken Notice” within five calendar days after the application date

Follow-up on all pended verification before issuance of on-going benefits beyond the initial expedited issuance period

PART ONE – CHECK YES OR NO

IS THE HOUSEHOLD ALREADY RECEIVING SNAP BENEFITS THIS MONTH?

NOTE: IF “YES” IS CHECKED, BUT HOUSEHOLD ENTERED A DOMESTIC VIOLENCE SHELTER DURING THE MONTH OF APPLICATION, CONTINUE WITH PART TWO.

YES - IF YES, HOUSEHOLD DOES

NOT QUALIFY FOR EXPEDITED PROCESSING COMPLETE PART FOUR

NO - IF NO, CONTINUE

WITH PART TWO

PART TWO – CHECK YES OR NO

** In determining GROSS INCOME, exclude non-countable income such as child support payments made to a person outside the household.

SECTION

A

CHECK YES OR NO

DOES THE HOUSEHOLD HAVE $100 OR LESS IN CASH, SAVINGS OR OTHER LIQUID RESOURCES, AND

YES – IF YES, HOUSEHOLD

QUALIFIES FOR EXPEDITED PROCESSING.

COMPLETE PART FOUR

NO – IF NO, CONTINUE

WITH SECTION B.

HAS THE HOUSEHOLD RECEIVED OR DOES IT EXPECT TO

RECEIVE LESS THAN $150 GROSS INCOME ** DURING THE

MONTH OF APPLICATION?

SECTION

B

ARE HOUSEHOLD’S TOTAL GROSS INCOME ** DURING MONTH OF APPLICATION PLUS THE HOUSEHOLD’S LIQUID RESOURCES LESS THAN THEIR MONTHLY RENT/MORTGAGE PLUS UTILITY EXPENSES?

YES

IF YES, HOUSEHOLD QUALIFIES FOR EXPEDITED PROCESSING. COMPLETE PART FOUR

NO

IF NO, HOUSEHOLD DOES NOT QUALIFY FOR EXPEDITED PROCESSING UNLESS QUALIFIED UNDER PART THREE.

GO TO PART THREE IF A MIGRANT/SEASONAL FARMWORKER OTHERWISE, COMPLETE PART FOUR

Rent/Mortgage: $ _____________ Income: $_____________

*Heat/AC: ______________Resources: ____________

*Utilities: ______________

*Telephone: ______________

*Homeless Shelter Deduction ______________

Total Expenses: $______________ Totals: ______________

* Use HT/AC Standard Utility Allowance (SUA) only if household incurs costs or received HEAP greater than $20 during the month of application or within the previous 12 months of application. ** Use the Homeless Shelter Deduction for “undomiciled” households who do not reside in a homeless shelter.

PART THREE – MIGRANT/SEASONAL FARM WORKER HOUSEHOLDS ONLY - CHECK YES OR NO

A. IS THIS A HOUSEHOLD WITH NO MORE THAN $100 IN LIQUID RESOURCES?

AND

YES NO – IF NO, HOUSEHOLD DOES NOT QUALIFY

FOR EXPEDITED PROCESSING. COMPLETE PART FOUR

B. THE ONLY INCOME FOR THE MONTH OF APPLICATION:

(1) WAS TERMINATED BEFORE APPLICATION?

OR

(2) IS NEW, AND NO MORE THAN $25 GROSS INCOME WILL BE RECEIVED WITHIN TEN DAYS AFTER APPLICATION

YES

YES

NO CONTINUE WITH B2

NO

IF YES TO QUESTION A, AND YES TO EITHER QUESTION B1 OR QUESTION B2, HOUSEHOLD QUALIFIES FOR EXPEDITED PROCESSING,

IF NO TO BOTH B1 & B2 HH DOES NOT QUALIFY, COMPLETE PART FOUR IN EITHER SITUATION

LDSS-3938 (Rev. 9/14)

PART FOUR - RESULTS OF EVALUATION FOR EXPEDITED APPLICATION PROCESSING - CHECK ONE

QUALIFIED FOR EXPEDITED APPLICATION PROCESSING. NOT QUALIFIED FOR

EXPEDITED APPLICATION PROCESSING STOP HERE

NOT ENOUGH INFORMATION IS

PROVIDED ON THE APPLICATION TO DETERMINE IF ELIGIBLE FOR EXPEDITED PROCESSING.

NOTES:

PART FIVE - ELIGIBILITY INTERVIEW – COMPLETE SECTIONS A

VERIFICATION - CHECK YES OR NO

SECTION A

1. CAN APPLICANT’S IDENTITY BE VERIFIED?

IF DOCUMENTARY EVIDENCE IS NOT READILY AVAILABLE, COLLATERAL CONTACTS ARE ACCEPTABLE. NO SPECIFIC DOCUMENT CAN BE REQUIRED.

YES, IF ELIGIBLE

BENEFITS CAN BE ISSUED PROVIDED ANY OUTSTANDING REQUIREMENTS HAVE BEEN MET GO TO QUESTION 2

NO

IF APPLICANT IS DEEMED ELIGIBLE, SNAP BENEFITS CANNOT BE ISSUED UNTIL VERIFICATION OF IDENTITY IS PROVIDED GO TO QUESTION 2

2. WAS THE HOUSEHOLD’S LAST ISSUANCE AN EXPEDITED ISSUANCE?

YES

GO TO QUESTION 3

NO

IF DEEMED ELIGIBLE, HH CAN RECEIVE BENEFITS WITH ALL OTHER VERIFICATION PENDED, CONTINUE TO SECTION B

3. IF YES TO QUESTION 2, HAS ALL RELEVANT VERIFICATION BEEN SUBMITTED?

YES

IF DEEMED ELIGIBLE HH CAN RECEIVE BENEFITS WITH ALL OTHER VERIFICATION PENDED, CONTINUE TO SECTION B

NO

If HH IS DEEMED ELIGIBLE, SNAP BENEFITS CANNOT BE ISSUED UNTIL ELIGIBILITY IS VERIFIED. ALLOW 10 DAYS FOR VERIFICATION TO BE SUBMITTED. DATE REQUESTED: _____________ DATE SUBMITTED: _____________

WORKING FAMILIES SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM INITIATIVE

SECTION B

PLEASE COMPLETE FOR NON-TA SNAP HOUSEHOLDS ONLY

1. IS ANY ADULT* (18 YEARS OF AGE OR OLDER) MEMBER OF YOUR YES – IF YES, HOUSEHOLD NO – IF NO, GO TO

HOUSEHOLD EITHER WORKING 30 OR MORE HOURS PER WEEK PRESUMPTIVELY QUALIFIES QUESTION 2 OR EARNING $217.50 OR MORE PER WEEK? FOR WFSNAPI

OR

2. ARE ANY TWO (2) ADULT* MEMBERS OF YOUR HOUSEHOLD EACH YES – IF YES, HOUSEHOLD NO – IF NO,

EITHER WORKING 20 OR MORE HOURS PER WEEK OR EARNING PRESUMPTIVELY QUALIFIES HOUSEHOLD DOES $145 OR MORE PER WEEK? FOR WFSNAPI NOT QUALIFY FOR WFSNAP

DATE ELIGIBILITY INTERVIEW:

WORKER NAME:

Appendix F –

Documentation Requirements Checklist

(LDSS-2642)

Appendix G –

SNAP Documentation Verification Desk Guide (LDSS-3666)

LD

SS-3

666

(Rev

.8/1

2) F

RO

NT

NEW

YO

RK

STA

TE O

FFIC

E O

F TE

MP

OR

AR

Y A

ND

DIS

AB

ILIT

Y A

SS

ISTA

NC

E

TA/S

UPP

LEM

ENTA

L N

UTR

ITIO

N A

SSIS

TAN

CE

PRO

GR

AM

(SN

AP)

DO

CU

MEN

TATI

ON

/VER

IFIC

ATI

ON

DES

K G

UID

E TA

SN

AP

ELIG

IBIL

ITY

FAC

TOR

PR

IMA

RY

SEC

ON

DA

RY

TA

SN

AP

ELIG

IBIL

ITY

FAC

TOR

PR

IMA

RY

M

M

Id

entit

y

Pho

to I.

D.

Drive

r’s L

ice

nse

US

Pas

spor

t N

atur

aliz

atio

n C

ertif

icat

e H

osp

ita

l/D

octo

r’s R

eco

rds

Ado

ptio

n P

aper

s Fo

r SN

AP – Id

entit

y is

onl

y m

anda

tory

for t

he p

erso

n m

akin

g th

e ap

plic

atio

n.

Sta

tem

ent f

rom

Ano

ther

Per

son

Soc

ial S

ecur

ity N

umbe

r B

irth/

Bapt

ism

al C

ertif

icat

e S

OLQ

Fo

r SN

AP

- In

the

case

of a

n au

thor

ized

re

pres

enta

tive,

bot

h th

e au

th re

p an

d ap

plic

ant m

ust v

erify

Iden

tity.

M

N

A

bsen

t Par

ent

Info

rmat

ion

Pay

Stu

bs

Tax

Ret

urns

S

ocia

l Sec

urity

or V

A R

ecor

ds

Une

mpl

oym

ent (

UIB

) Boo

k ID

Car

ds (H

ealth

Insu

ranc

e)

Drive

r’s L

ice

nse o

r R

egis

tration

M

N

M

arita

l Sta

tus

Mar

riage

/Dea

th C

ertif

icat

es

Sep

arat

ion

Agr

eem

ent

Div

orce

Dec

ree

Soc

ial S

ecur

ity R

ecor

ds

VA

Rec

ords

Sta

tem

ent f

rom

Cle

rgy

Cen

sus

Rec

ords

N

ewsp

aper

Not

ice

Sta

tem

ent f

rom

Ano

ther

Per

son

M

M *

Soci

al S

ecur

ity

Num

ber

Soc

ial S

ecur

ity C

ard

Offi

cial

Cor

resp

onde

nce

from

SS

A Fo

r TA

and

SN

AP,

pro

vide

d or

app

ly fo

r # a

t ce

rtific

atio

n; m

ust v

erify

at f

irst r

ecer

tific

atio

n un

less

va

lidat

ed b

y W

MS

SO

LQ

M

M *

Res

iden

ce

Sta

tem

ent f

rom

Lan

dlor

d C

urre

nt R

ent R

ecei

pt o

r Lea

se

Mor

tgag

e R

ecor

ds

For S

NA

P- R

esid

ence

is

verif

ied

at a

hou

seho

ld le

vel

Sta

tem

ent f

rom

Ano

ther

Per

son

Cur

rent

Mai

l S

choo

l Rec

ords

Fu

el/U

tility

bill

M

M

Q

M

Citi

zens

hip

Alie

n St

atus

Birt

h/Ba

ptis

mal

Cer

tific

ate

H

ospi

tal R

ecor

ds

US

Pas

spor

t M

ilitar

y S

ervi

ce R

ecor

ds

Nat

ural

izat

ion

Cer

tific

ate

US

CIS

Doc

umen

tatio

n Ev

iden

ce o

f Con

tinuo

us U

S R

esid

ence

sin

ce P

rior t

o 1/

1/72

Fo

r TA

and

SN

AP,

alie

n st

atus

is v

erifi

ed o

n an

in

divi

dual

bas

is

For S

NA

P O

nly,

citi

zens

hip

is v

erifi

ed o

nly

if qu

estio

nabl

e

M

M *

Hou

seho

ld

Com

posi

tion/

Size

Sta

tem

ent f

rom

N

on-r

elat

ive

Land

lord

Fo

r SN

AP –

hou

seho

ld s

ize

mus

t be

verif

ied.

Thi

s ca

n be

do

ne th

roug

h co

llate

ral

cont

acts

or r

eadi

ly a

vaila

ble

docu

men

ts w

hich

can

be

used

to

est

ablis

h Id

entit

y.

Sta

tem

ent f

rom

Oth

er P

erso

ns

M

M *

Earn

ed In

com

e

Cur

rent

Wag

e St

ubs

and

Stat

emen

t of T

ips

Pay

Env

elop

es

Con

tact

with

Em

ploy

er

Bus

ines

s R

ecor

ds

Rec

ords

and

Rel

ated

Mat

eria

ls C

once

rnin

g S

elf-

Em

ploy

men

t Ear

ning

s an

d E

xpen

ses

Cur

rent

Inco

me

Tax

Ret

urn

Sta

tem

ent f

rom

Roo

mer

, Boa

rder

, Ten

ant

Inco

me

Tax

Rec

ords

M

M *

Age

Birt

h C

ertif

icat

e B

aptis

mal

Cer

tific

ate

Hos

pita

l Rec

ords

A

dopt

ion

Rec

ords

N

atur

aliz

atio

n C

ertif

icat

e D

rive

r’s L

ice

nse

For S

NA

P O

nly,

DO

B c

an b

e V

erifi

ed a

t Rec

ertif

icat

ion

Insu

ranc

e Po

licy

Cen

sus

Rec

ords

S

choo

l Rec

ords

S

tate

men

t fro

m A

noth

er P

erso

n P

hysi

cian

Sta

tem

ent

Offi

cial

Cor

resp

onde

nce

from

SSA

M

M *

Une

arne

d In

com

e

Sta

tem

ent f

rom

Fam

ily C

ourt

Sta

tem

ent f

rom

Per

son

Pay

ing

S

tate

men

t fro

m S

choo

l S

tate

men

t fro

m B

ank

or C

redi

t Uni

on

Sta

tem

ent f

rom

Bro

ker/A

gent

S

uppo

rt C

heck

stu

bs

Cur

rent

Aw

ard

Cer

tific

ate

Cur

rent

Ben

efit

Che

ck

Offi

cial

Cor

resp

onde

nce

with

NY

S D

ept.

of L

abor

O

ffici

al C

orre

spon

denc

e fro

m S

SA

Offi

cial

Cor

resp

onde

nce

from

VA

Offi

cial

Cor

resp

onde

nce

from

sou

rce

of in

com

e A

war

d Le

tter

M

N

A

bsen

t Par

ent

Dea

th C

ertif

icat

e S

urv

ivo

r’s B

en

efits

H

ospi

tal R

ecor

ds

VA

or M

ilitar

y R

ecor

ds

Div

orce

Pap

ers

Pro

of o

f Rem

arria

ge

New

spap

er N

otic

e In

sura

nce

Com

pany

Rec

ords

In

stitu

tiona

l Rec

ords

A

genc

y C

ase

Rec

ords

and

B

uria

l Pay

men

t Lin

es

Sta

tem

ent f

rom

a N

on-R

elat

ive

LE

GE

ND

: M

=

Man

dato

ry D

ocum

enta

tion/

Verif

icat

ion

requ

ired

for C

ertif

icat

ion

Q =

Ver

ifica

tion

is O

nly

Nec

essa

ry if

Que

stio

nabl

e N

=

No

Doc

umen

tatio

n/Ve

rific

atio

n re

quire

d O

=

Opt

iona

l Doc

umen

tatio

n/V

erifi

catio

n (m

ay b

e ne

cess

ary

for T

A a

nd/o

r SN

AP

elig

ibilit

y or

ben

efit

amou

nt.)

* =

Ver

ifica

tion

can

be p

ende

d un

der S

NA

P E

xped

ited

Pro

cess

ing

L

DSS

-366

6 (R

ev. 8

/12)

REV

ER

SE

NEW

YO

RK

STA

TE O

FFIC

E O

F TE

MP

OR

AR

Y A

ND

DIS

AB

ILIT

Y A

SS

ISTA

NC

E

TA/S

UPP

LEM

ENTA

L N

UTR

ITIO

N A

SSIS

TAN

CE

PRO

GR

AM

(SN

AP)

DO

CU

MEN

TATI

ON

/VER

IFIC

ATI

ON

DES

K A

ID

TA

SNA

P EL

IGIB

ILIT

Y FA

CTO

R

PRIM

AR

Y

EXPE

NSE

S TH

AT

MA

Y A

FFEC

T EL

IGIB

ILIT

Y O

R B

ENEF

IT A

MO

UN

T

M

M *

Res

ourc

es

Sta

tem

ent f

rom

hou

seho

ld

Sta

tem

ent f

rom

nur

sing

hom

e C

urre

nt b

ank

reco

rds

Cur

rent

cre

dit u

nion

reco

rds

Sto

ck c

ertif

icat

e B

onds

S

tate

men

t fro

m fi

nanc

ial i

nstit

utio

n

Insu

ranc

e po

licy

Sta

tem

ent f

rom

insu

ranc

e co

mpa

ny

Bur

ial a

gree

men

t B

uria

l plo

t dee

d S

tate

men

t fro

m fu

nera

l dire

ctor

Ref

und

or E

ITC

che

ck

Sta

tem

ent f

rom

tax

offic

e

Dee

d S

tate

men

t fro

m re

al e

stat

e br

oker

A

ppra

isal

/est

imat

e of

cur

rent

val

ue b

y br

oker

Ti

tle o

f ow

ners

hip

Reg

istra

tion

(old

er m

odel

s)

App

rais

al o

f cur

rent

val

ue b

y de

aler

Fi

nanc

ing

data

Sta

tem

ent f

rom

sou

rce

of p

aym

ent

TA

SNA

P EL

IGIB

ILIT

Y FA

CTO

R

PRIM

AR

Y

O

O

*

She

lter

Expe

nses

Cur

rent

rent

rece

ipt

Cur

rent

leas

e M

ortg

age

book

/reco

rds

Pro

perty

and

sch

ool t

ax re

cord

s La

ndlo

rd s

tate

men

t S

ewer

and

wat

er b

ills

Hom

eow

ner’s insura

nce re

cord

s Fu

el b

ills

Non

-hea

ting

utilit

y bi

lls

Tel

epho

ne b

ills

O

O

*

Med

ical

Bill

s

Cop

ies

of m

edic

al b

ills (p

aid

and

unpa

id)

Pro

vide

r Sta

tem

ent o

f Hea

lth In

sura

nce

prem

ium

s M

edic

are

Pre

scrip

tion

Dru

g C

ard

For S

NAP

, for

A/D

indi

vidu

als

only

O

O

*

Unp

aid

Bill

s R

ent,

Util

ity

Cop

y of

eac

h bi

ll sh

owin

g am

ount

ow

ed, p

erio

d of

se

rvic

es a

nd p

rovi

der

O

O

*

Oth

er E

xpen

ses

Dep

ende

nt C

are

Cos

t

Cou

rt or

der

Sta

tem

ent f

rom

day

car

e ce

nter

or o

ther

chi

ld c

are

prov

ider

S

tate

men

t fro

m a

ide

or a

ttend

ant

Can

celle

d ch

ecks

or r

ecei

pts

M

O

*

Hea

lth

Insu

ranc

e

Insu

ranc

e po

licy

Insu

ranc

e ca

rd

Sta

tem

ent f

rom

pro

vide

r of c

over

age

Med

icar

e ca

rd

M

O

*

Dis

able

d/

Inca

paci

tate

d/

Preg

nant

Sta

tem

ent f

rom

med

ical

pro

fess

iona

l ver

ifyin

g pr

egna

ncy

and

expe

cted

dat

e of

birt

h S

tate

men

t fro

m m

edic

al p

rofe

ssio

nal

Pro

of o

f SSA

or S

SI b

enef

its fo

r dis

abilit

y or

blin

dnes

s

M

M

*

Able

-Bod

ied

Adul

t W

ithou

t D

epen

dent

s (A

BAW

D) E

ligib

ility

For

non-

wai

ver

area

s an

d no

n-ex

clud

ed

ABA

WD

in

divi

dual

s P

roof

of w

orki

ng a

nd/o

r w

ork

prog

ram

par

ticip

atio

n fo

r at

leas

t 80

hour

s pe

r mon

th

Che

ck T

ime

Lim

it Tr

acki

ng M

enu

(#17

on

WM

S m

enu)

fo

r 3

or m

ore

mon

ths

of F

S r

ecei

pt in

pas

t 36

mon

ths

with

out m

eetin

g AB

AWD

wor

k re

quire

men

t

M

O

*

Ref

erra

l S

tate

men

t fro

m p

rovi

der o

f tre

atm

ent

Sta

tem

ent f

rom

em

ploy

men

t ser

vice

*L

EG

EN

D: M

=

Man

dato

ry D

ocum

enta

tion/

Verif

icat

ion

requ

ired

for C

ertif

icat

ion

N

=

No

Doc

umen

tatio

n/V

erifi

catio

n re

quire

d O

=

Opt

iona

l D

ocum

enta

tion/

Ver

ifica

tion

(may

be

nece

ssar

y fo

r TA

an

d/or

SN

AP

elig

ibili

ty o

r ben

efit

amou

nt.)

Q

= V

erifi

catio

n is

onl

y ne

cess

ary

if qu

estio

nabl

e *

= V

erifi

catio

n ca

n be

pen

ded

unde

r SN

AP

Exp

edite

d P

roce

ssin

g O

O

*

Scho

ol

Atte

ndan

ce

Sch

ool r

ecor

ds (

curre

nt re

port

card

) S

tate

men

t fro

m s

choo

l Fo

r SN

AP, a

ffect

s w

ork

regi

stra

tion

and

earn

ings

of

child

ren

unde

r 18

Appendix H –

Non-Citizen Eligibility Chart (LDSS-4579)

LDSS

-457

9 (R

ev. 8

/12)

A

LIEN

ELI

GIB

ILIT

Y D

ESK

AID

Pa

ge 1

Des

crip

tion

of S

tatu

s W

MS/

AC

I C

ode

Com

mon

Doc

umen

tatio

n

Rel

evan

t D

ate

for

Elig

ibili

ty

M

edic

aid

1

Fam

ily

Assi

stan

ce

Safe

ty N

et

Assi

stan

ce

Supp

lem

enta

l Nut

ritio

n As

sist

ance

Pro

gram

(S

NAP

) Ben

efits

Ref

ugee

s R

I-94:

sta

mped “

Adm

itte

d u

nder

Sectio

n 2

07

of

the I

NA

,” “

Refu

gee,”

“R

E1, R

E2,

RE

3,

RE

4”

or

I-5

51: s

tam

ped “R

8-6

, RE

5, R

E6,

RE

7, R

E8

or

RE

9”

or

I-571

: Ref

ugee

Tra

vel D

ocum

ent

or

I-688

B:

Empl

oym

ent A

utho

rizat

ion

Doc

umen

t annota

ted w

ith “

8 C

.F.R

. § 2

74a.

12(a

) (3

)”

or

I-7

66:

Empl

oym

ent A

utho

rizat

ion

Doc

umen

t annota

ted “

a3”

Entr

y

Yes

Cub

an/H

aitia

n En

tran

ts

H

I-94:

sta

mped “

Cuban/H

aitia

n E

ntr

ant

(sta

tus

pendin

g),

” “S

ectio

n 2

12(d

) (5

) of th

e I

NA

,” “

Fo

rm

I-589 f

iled,”

or

“CU

6,”

or

CU

7”

or

I-9

4 st

amp

show

ing

paro

le u

nder

Sec

tion

212(

d)(5

) of I

NA

or s

tam

p sh

owin

g pa

role

in U

S

on o

r afte

r 10/

10/8

0 an

d re

ason

able

evi

denc

e th

at p

arol

ee h

as b

een

a N

atio

nal (

citiz

en) o

f C

uba

or H

aiti2

or

I-551

: sta

mp

ed “

CU

6,

CU

7,

or

CH

6”

or

Tem

pora

ry I-

551

stam

p in

fore

ign

pass

port.

or

US

CIS

not

ice

or le

tter i

ndic

atin

g on

goin

g ex

clus

ion

or d

epor

tatio

n pr

ocee

ding

s

Stat

us

Gra

nted

Asyl

ees

A

I-94:

sta

mped “

Gra

nte

d a

sylu

m u

nder

Sectio

n

208 o

f th

e I

NA

” or

I-5

51: S

tam

ped “

AS

1,A

S2, A

S3, A

S6, A

S7,

or

AS

8”

or

I-688

B:

Empl

oym

ent A

utho

rizat

ion

Car

d annota

ted w

ith “

8 C

.F.R

. § 2

74a.

12(a

)(5)”

or

I-7

66:

Empl

oym

ent A

utho

rizat

ion

Doc

umen

t annota

ted “

(a5)

” or

G

rant

lette

r fro

m U

SC

IS A

sylu

m O

ffice

or

O

rder

of a

n im

mig

ratio

n ju

dge

gran

ting

asyl

um.

1 REM

IND

ER: F

or M

edic

aid,

und

ocum

ente

d al

iens

and

tem

pora

ry n

on-im

mig

rant

s m

ay re

ceiv

e co

vera

ge fo

r car

e an

d se

rvic

es n

eces

sary

for t

he tr

eatm

ent o

f em

erg

en

cy m

edic

al c

ondi

tions

on

ly, n

ot in

clud

ing

care

and

ser

vice

s re

late

d to

an

orga

n tr

ansp

lant

pro

cedu

re, i

f oth

erw

ise

elig

ible

. Pr

egna

nt w

omen

may

be

prov

ided

Med

icai

d at

an

y t

ime w

ithou

t reg

ard

to a

lien

stat

us, i

f ot

herw

ise

elig

ible

. Chi

ldre

n m

ay b

e pr

ovid

ed m

edic

al a

ssis

tanc

e w

ithou

t reg

ard

to im

mig

ratio

n st

atus

und

er C

hild

Hea

lth P

lus

(CH

Plu

s) p

rogr

am.

2 EXC

EPTI

ON

: Th

is g

uide

line

does

not

app

ly w

hen

the

indi

vidu

al w

as p

arol

ed s

olel

y to

test

ify a

s a

witn

ess

in a

judi

cial

, adm

inis

trat

ive

or le

gisl

ativ

e pr

ocee

ding

or w

hen

the

paro

lee

is in

lega

l cu

stod

y pe

ndin

g cr

imin

al p

rose

cutio

n.

LDSS

-457

9 (R

ev. 8

/12)

A

LIEN

ELI

GIB

ILIT

Y D

ESK

AID

Pa

ge 2

Des

crip

tion

of S

tatu

s W

MS/

AC

I C

ode

Com

mon

Doc

umen

tatio

n

Rel

evan

t D

ate

for

Elig

ibili

ty

M

edic

aid

1

Fam

ily

Assi

stan

ce

Safe

ty N

et

Assi

stan

ce

Supp

lem

enta

l Nut

ritio

n As

sist

ance

Pro

gram

(S

NAP

) Ben

efits

Amer

asia

n Im

mig

rant

s

R

I-94:

sta

mped “

AM

1, A

M2, A

M3, A

M6,

AM

7,

or

AM

8.”

D

erive d

ate

of entr

y f

rom

date

of

insp

ectio

n on

sta

mp;

if d

ate

is m

issi

ng, o

btai

n fro

m I-

551

or fr

om U

SC

IS

or

I-5

51: s

tam

ped “

AM

1, A

M2, A

M3, A

M6,

AM

7, or

AM

8”

or

Tem

pora

ry I-

551

stam

p in

fore

ign

pass

port

or

1-57

1: R

efug

ee T

rave

l Doc

umen

t

or

Vie

tnam

ese e

xit v

isa o

r passport

sta

mped “

AM

1,

AM

2,

or

AM

3”

Entr

y

Yes

Dep

orta

tion

or R

emov

al

With

held

J

I-688

B:

Empl

oym

ent A

utho

rizat

ion

Car

d annota

ted w

ith “

8 C

.F.R

. §

274a.1

2(a

)(10)”

or

I-7

66:

Empl

oym

ent A

utho

rizat

ion

Doc

umen

t annota

ted “

(a10)”

or

O

rder

from

Imm

igra

tion

Judg

e sh

owin

g th

e da

te

depo

rtatio

n w

as w

ithhe

ld u

nder

Sec

tion

243(

h) o

f th

e IN

A a

s in

effe

ct p

rior t

o A

pril

1, 1

997,

or

rem

oval

with

held

und

er S

ectio

n 24

1(b)

(3) o

f IN

A

Stat

us

Gra

nted

Cer

tain

Hm

ong

or H

ighl

and

Laot

ian

Z

R (M

A)

I-94:

sta

mped “

Adm

itte

d u

nder

Sectio

n 2

07 o

f th

e I

NA

,” “

Refu

gee,”

“R

E1, R

E2,

RE

3,

or

RE

4”

or

INS

I-551

: S

tam

ped “

RE

5, R

E6, R

E7,

RE

8, or

RE

9”

or

Has

a s

igne

d af

fidav

it sw

orn

unde

r pen

alty

of l

aw

that

s/h

e w

as a

mem

ber o

f Hm

ong

or H

ighl

and

Laot

ian

tribe

bet

wee

n 8/

5/64

and

5/7

/75

or a

ve

rifie

d sp

ouse

*, w

idow

, wid

ower

or u

nmar

ried

depe

nden

t of a

trib

al m

embe

r a

nd

Doc

umen

ts to

sho

w la

wfu

lly re

sidi

ng in

the

US

*Div

orce

d sp

ouse

s do

not

qua

lify

1 R

EMIN

DER

: For

Med

icai

d, u

ndoc

umen

ted

alie

ns a

nd te

mpo

rary

non

-imm

igra

nts

may

rece

ive

cove

rage

for c

are

and

serv

ices

nec

essa

ry fo

r the

trea

tmen

t of e

merg

en

cy m

edic

al c

ondi

tions

on

ly, n

ot in

clud

ing

care

and

ser

vice

s re

late

d to

an

orga

n tr

ansp

lant

pro

cedu

re, i

f oth

erw

ise

elig

ible

. Pr

egna

nt w

omen

may

be

prov

ided

Med

icai

d at

an

y t

ime w

ithou

t reg

ard

to a

lien

stat

us, i

f ot

herw

ise

elig

ible

. Chi

ldre

n m

ay b

e pr

ovid

ed m

edic

al a

ssis

tanc

e w

ithou

t reg

ard

to im

mig

ratio

n st

atus

und

er C

hild

Hea

lth P

lus

(CH

Plu

s) p

rogr

am.

LDSS

-457

9 (R

ev. 8

/12)

A

LIEN

ELI

GIB

ILIT

Y D

ESK

AID

Pa

ge 3

D

escr

iptio

n of

Sta

tus

WM

S/

ACI

Cod

e C

omm

on D

ocum

enta

tion

R

elev

ant

Dat

e fo

r El

igib

ility

Med

icai

d 1

Fam

ily A

ssis

tanc

e Sa

fety

Net

As

sist

ance

SN

AP

Ben

efits

* La

wfu

lly A

dmitt

ed

For P

erm

anen

t R

esid

ence

(LPR

) with

40

Qua

lifyi

ng Q

uart

ers

S

I-551

: (P

erm

anen

t Res

iden

t Car

d)

or

Tem

pora

ry I-

551

stam

p in

fore

ign

pass

port

or

on I-

94

or

I-327

: (R

e-en

try P

erm

it)

or

I-1

81:

Mem

oran

dum

of C

reat

ion

of L

awfu

l P

erm

anen

t Res

iden

ce w

ith a

ppro

val s

tam

p

and

Proo

f of q

ualif

ying

qua

rter

s

Ente

red

Bef

ore

8/22

/96

Yes

Ente

red

On/

Afte

r 08

/22/

96

Yes

Yes,

afte

r 5 y

ears

in U

S in

a

qual

ified

sta

tus

Ye

s

Law

fully

Adm

itted

For

Pe

rman

ent R

esid

ence

(L

PR) w

ithou

t 40

Q

ualif

ying

Qua

rter

s K

I-551

: (P

erm

anen

t Res

iden

t Car

d)

or

Tem

pora

ry I-

551

stam

p in

fore

ign

pass

port

or

on I-

94.

or

I-327

(Re-

entry

Per

mit)

or

I-1

81:

Mem

oran

dum

of C

reat

ion

of L

awfu

l P

erm

anen

t Res

iden

ce w

ith a

ppro

val s

tam

p

Ente

red

Bef

ore

8-22

-96

Ye

s Ye

s

Yes

if:

In

a q

ualif

ied

stat

us

and

in re

ceip

t of

cert

ain

disa

bilit

y be

nefit

s

[7 U

SC 2

012(

r)]

or

Af

ter f

ive

year

s in

US

in

a qu

alifi

ed s

tatu

s

o

r

In a

qua

lifie

d st

atus

and

un

der a

ge 1

8

Ente

red

On

or

Afte

r 08

/22/

96

Yes

Yes,

afte

r 5 y

ears

in U

S in

a

qual

ified

sta

tus

Yes

Vete

ran,

spo

use,

un

mar

ried

surv

ivin

g sp

ouse

and

unm

arrie

d de

pend

ent c

hild

of a

U

.S. v

eter

an w

ho

fulfi

lled

min

imum

ac

tive

duty

re

quire

men

t (2

year

s)

V

A D

isch

arge

Cer

tific

ate

(For

m D

D-2

14) t

hat

sta

tes “

Honora

ble

.” A

chara

cte

r of dis

charg

e

“Under

Honora

ble

Conditio

ns”

is n

ot

an

“Honora

ble

Dis

charg

e”

for

these p

urp

oses.

Nar

rativ

e R

easo

n fo

r Sep

arat

ion

bloc

k m

ust

not s

tate

that

dis

char

ge w

as fo

r rea

son

of

“alie

nage”

or

lack o

f U

.S. citi

zens

hip.

Stat

us

Gra

nted

Ye

s

Activ

e M

ilita

ry:

Activ

e du

ty o

r a m

embe

r of

the

Arm

ed F

orce

s on

fu

ll-tim

e du

ty in

the

Arm

y, N

avy,

Air

Forc

e,

Mar

ine

Cor

ps o

r Coa

st

Gua

rd, s

pous

e an

d ch

ildre

n

M

Mili

tary

Iden

tific

atio

n C

ard

(DD

For

m 2

) (Ac

tive)

th

at li

sts

an e

xpira

tion

date

of m

ore

than

one

ye

ar fr

om th

e da

te o

f det

erm

inat

ion.

If I

D c

ard

is d

ue to

exp

ire w

ithin

one

yea

r fro

m th

e da

te

of d

eter

min

atio

n, u

se a

cop

y of

cur

rent

milit

ary

orde

rs.

Stat

us

Gra

nted

Ye

s

Con

ditio

nal E

ntra

nt

(sta

tus

gran

ted

to

refu

gees

bef

ore

1980

) F

I-94

with

sta

mp

show

ing

adm

itted

und

er

Sec

tion

203(

a)(7

) of I

NA

or

I-6

88B

(Em

ploy

men

t Aut

horiz

atio

n C

ard)

annota

ted “

274a

.12(a

)(3)”

or

I-7

66 (E

mpl

oym

ent A

utho

rizat

ion

Doc

umen

t) an

nota

ted

“(A1)

” or “

(A3)

”

Entr

y Ye

s

*No

quar

ters

ear

ned

afte

r 12/

31/9

6 m

ay b

e co

unte

d in

whi

ch a

n al

ien

has

rece

ived

a F

eder

al m

eans

-test

ed p

ublic

ben

efit

(FA,

SSI

, SN

AP o

r Med

icai

d.)

1 REM

IND

ER: F

or M

edic

aid,

und

ocum

ente

d al

iens

and

tem

pora

ry n

on-im

mig

rant

s m

ay re

ceiv

e co

vera

ge fo

r car

e an

d se

rvic

es n

eces

sary

for t

he tr

eatm

ent o

f em

erg

en

cy m

edic

al c

ondi

tions

on

ly, n

ot in

clud

ing

care

and

ser

vice

s re

late

d to

an

orga

n tr

ansp

lant

pro

cedu

re, i

f oth

erw

ise

elig

ible

. Pr

egna

nt w

omen

may

be

prov

ided

Med

icai

d at

an

y t

ime w

ithou

t reg

ard

alie

n st

atus

, if

othe

rwis

e el

igib

le.

Chi

ldre

n m

ay b

e pr

ovid

ed m

edic

al a

ssis

tanc

e w

ithou

t reg

ard

to im

mig

ratio

n st

atus

und

er C

hild

Hea

lth P

lus

(CH

Plu

s) p

rogr

am.

LDSS

-457

9 (R

ev. 8

/12)

A

LIEN

ELI

GIB

ILIT

Y D

ESK

AID

Pa

ge 4

Des

crip

tion

of S

tatu

s W

MS/

AC

I C

ode

Com

mon

Doc

umen

tatio

n

Rel

evan

t Dat

e fo

r El

igib

ility

M

edic

aid

1

Fam

ily

Assi

stan

ce

Safe

ty N

et

Assi

stan

ce

SNAP

B

enef

its

A U

S cit

izen

’s o

r L

PR

’s

batte

red

spou

se,

or

ch

ild,

or p

aren

t or

chi

ld

of s

uch

batte

red

pers

on,

who

obt

ains

"N

otic

e of

Pr

ima

Faci

e C

ase

from

U

SCIS

un

der

the

Viol

ence

Aga

inst

Wom

en

Act (

VAW

A)

B3

I-797

(Not

ice

of A

ctio

n) in

dica

ting

prim

a fa

cie

elig

ibilit

y of

an

I-360

sel

f-pet

ition

und

er

INA

Sec

tion

204(

a)(1

)(A) (

iii) o

r (iv

);

or

IN

A S

ectio

n 20

4(a)

(1)(i

ii)(B

) (i )

or (

iii)

Ente

red

Bef

ore

8/22

/96

Yes

Yes

Yes

Y

es if

:

In a

qua

lifie

d st

atus

and

in

rece

ipt o

f cer

tain

di

sabi

lity

bene

fits

[7 U

SC 2

012(

r)]

o

r

Afte

r fiv

e ye

ars

in U

S in

a

qual

ified

sta

tus

or

In

a q

ualif

ied

stat

us a

nd

unde

r age

18

or

In

a q

ualif

ied

stat

us a

nd

have

40

qual

ifyin

g qu

arte

rs

Ente

red

On/

Afte

r 8/

22/9

6

The

rele

vant

dat

e

for e

ligib

ility

is th

e da

te q

ualif

ied

stat

us w

as

obta

ined

Yes

Yes,

afte

r 5

year

s in

US

in a

qu

alifi

ed s

tatu

s Ye

s

A U

.S.

cit

izen

’s o

r L

PR

’s

batte

red

spou

se, o

r ch

ild, o

r par

ent o

r chi

ld

of s

uch

batte

red

pers

on,

who

se

I-360

sel

f – p

etiti

on u

nder

VA

WA

is a

ppro

ved

I-797

(N

otic

e of

Act

ion)

ind

icat

ing

appr

oval

of

an

I-360

sel

f-pet

ition

und

er I

NA

Sec

tion

204(

a)(1

)(A)(i

ii) o

r (iv

),

or

INA

Sec

tion

204(

a)(1

)(iii)

(B) (

i) or

(iii)

Ente

red

Bef

ore

8/22

/96

Yes

Yes

Yes

Ente

red

On/

Afte

r 8/

22/9

6 Th

e re

leva

nt d

ate

fo

r elig

ibili

ty is

the

date

qua

lifie

d st

atus

was

ob

tain

ed

Yes

Yes,

afte

r 5

year

s in

US

in a

qu

alifi

ed s

tatu

s Ye

s

A U

.S.

cit

izen

’s o

r L

PR

’s

batte

red

spou

se o

r chi

ld

or p

aren

t or c

hild

of s

uch

batte

red

per

son,

who

se

I-360

sel

f-pet

ition

und

er

VAW

A is

pen

ding

and

is

dete

rmin

ed to

be

a cr

edib

le v

ictim

of

dom

estic

vio

lenc

e by

the

so

cia

l serv

ices d

istr

ict’

s

Dom

estic

Vio

lenc

e Li

aiso

n (D

VL)

I-797

(N

otic

e of

Act

ion)

indi

catin

g pe

ndin

g I-

360

self-

petit

ion

unde

r

INA

S

ectio

n 20

4(a)

(1)(A

)(iii)

or (

iv),

or

IN

A S

ectio

n 20

4(a)

(1)(i

ii)(B

) (i)

or (i

ii)

En

tere

d B

efor

e 8/

22/9

6

Yes

Yes

Yes

Ente

red

On/

Afte

r 8/

22/9

6 Th

e re

leva

nt d

ate

fo

r elig

ibili

ty is

the

date

qua

lifie

d st

atus

was

ob

tain

ed

Yes

Yes,

afte

r 5

year

s in

US

in a

qu

alifi

ed s

tatu

s Ye

s

LDSS

-457

9 (R

ev. 8

/12)

A

LIEN

ELI

GIB

ILIT

Y D

ESK

AID

Pa

ge 5

D

escr

iptio

n of

Sta

tus

WM

S/

ACI

Cod

e C

omm

on D

ocum

enta

tion

R

elev

ant D

ate

for

Elig

ibili

ty

Med

icai

d 1

Fam

ily

Assi

stan

ce

Safe

ty N

et

Assi

stan

ce

SNAP

B

enef

its

An

alie

n de

term

ined

to

be a

cre

dibl

e vi

ctim

of

dom

estic

vio

lenc

e by

the

so

cia

l serv

ices d

istr

ict’

s

DVL

with

a p

endi

ng o

r ap

prov

ed I-

130

petit

ion

I-797

(N

otic

e of

Act

ion)

ind

icat

ing

appr

oval

or

pen

ding

I-13

0 vi

sa p

etiti

on u

nder

Sec

tion

201(

b) o

f the

INA

(spo

use

or c

hild

of a

U.S

. ci

tizen

) or

Sec

tion

203(

a)(2

)(A)

(spo

use

or

child

of a

per

man

ent l

egal

resi

dent

);

or

I-94

code

d K

3, K

4, V

1, V

2 or

CR

-1-7

and

a

pend

ing

or a

ppro

ved

I-13

0;

or

Any

oth

er U

SC

IS d

ocum

ent i

ndic

atin

g th

e al

ien

has

a K

or V

vis

a an

d a

pend

ing

or

appr

oved

I-13

0;

or

I-688

B o

r I-7

66 (

Empl

oym

ent

Aut

horiz

atio

n D

ocum

ents

) ann

otat

ed (a

)(9) o

r (a)

(15)

Ente

red

Bef

ore

8/22

/96

Ye

s Ye

s Ye

s

Ente

red

On/

Afte

r 8/

22/9

6 Th

e re

leva

nt d

ate

fo

r elig

ibili

ty is

the

date

qua

lifie

d st

atus

was

ob

tain

ed

Yes

Yes,

afte

r 5

year

s in

US

in a

qu

alifi

ed s

tatu

s Ye

s

An a

pplic

atio

n fo

r VAW

A ca

ncel

latio

n of

rem

oval

or

sus

pens

ion

of

depo

rtat

ion

has

been

gr

ante

d or

is p

endi

ng

and

the

imm

igra

tion

cour

t fin

ds th

at a

pplic

ant

has

a pr

ima

faci

e ca

se

for t

his

relie

f

B3

(Co

nt’

d.)

Ord

er

from

th

e E

xecu

tive

Offi

ce

of

Imm

igra

tion

Rev

iew

(E

OIR

) un

der

INA

24

0A(b

) or

if

the

appl

icat

ion

is

pend

ing

docu

men

tatio

n th

at t

he c

ourt

finds

tha

t th

e applic

ant

has a “p

rim

a fa

cie

case”

for

this

re

lief

Ente

red

Bef

ore

8/22

/96

Yes

Yes

Yes

Yes,

If:

In

a q

ualif

ied

stat

us a

nd

in re

ceip

t of c

erta

in

disa

bilit

y be

nefit

s

[7 U

SC 2

012(

r)]

or

Af

ter f

ive

year

s in

US

in

qual

ified

sta

tus

o

r

In a

qua

lifie

d st

atus

and

un

der a

ge 1

8

or

In

a q

ualif

ied

stat

us a

nd

have

40

qual

ifyin

g qu

arte

rs

Ente

red

On/

Afte

r 8/

22/9

6 Th

e re

leva

nt d

ate

fo

r elig

ibili

ty is

the

date

qua

lifie

d st

atus

was

ob

tain

ed

Yes,

afte

r 5

year

s in

US

in a

qu

alifi

ed s

tatu

s

Yes

LDSS

-457

9 (R

ev. 8

/12)

A

LIEN

ELI

GIB

ILIT

Y D

ESK

AID

Pa

ge 6

D

escr

iptio

n of

Sta

tus

WM

S/

ACI

Cod

e C

omm

on D

ocum

enta

tion

R

elev

ant D

ate

for

Elig

ibili

ty

Med

icai

d 1

Fam

ily

Assi

stan

ce

Safe

ty N

et

Assi

stan

ce

SNAP

B

enef

its

Vict

im o

f Hum

an

Traf

ficki

ng

D

(Ups

tate

)

R (N

YC)

Cer

tific

atio

n D

ocum

ent (

for a

dults

) or

Elig

ibilit

y Le

tter (

for c

hild

ren)

from

the

Offi

ce

of R

efug

ee R

eset

tlem

ent (

OR

R);

Mus

t cal

l 1-

866-

401-

5510

for v

erifi

catio

n

o

r I-9

4 C

oded

T1,

T2,

T3,

T4

or T

5 st

atin

g ad

mis

sion

und

er S

ectio

n 21

2(d)

(5) o

f the

IN

A if

sta

tus

gran

ted

for a

t lea

st o

ne y

ear

Entr

y4 Ye

s

Paro

lee

(for a

t lea

st o

ne

year

) (N

on-c

itize

ns w

ho

have

bee

n al

low

ed to

co

me

into

the

U.S

. for

hu

man

itaria

n or

pub

lic

inte

rest

reas

ons)

G

I-94

with

ann

ota

tio

n

“Paro

led

purs

uant

to

Sectio

n 2

12(d

)(5)”

or

“paro

le”

or

“PIP

” w

ith

date

of

en

try

and

date

of

ex

pira

tion

indi

catin

g on

e ye

ar

or

I-688

B

annota

ted

“8

CF

R

Sectio

n

274a

12(a

)(4)

or

274(a

) 12(c

)(11)”

or

I-766

an

nota

ted

“C11”

or

A4,

and

I-

94 in

dica

ting

adm

itted

for a

t lea

st o

ne y

ear

Ente

red

befo

re

8/22

/96

Yes

Yes,

If:

In

a q

ualif

ied

stat

us a

nd

in re

ceip

t of c

erta

in

disa

bilit

y be

nefit

s

[7 U

SC 2

012(

r)]

or

Af

ter f

ive

year

s in

US

in

qual

ified

sta

tus

o

r

In

a q

ualif

ied

stat

us a

nd

unde

r age

18

or

In

a q

ualif

ied

stat

us a

nd

have

40

qual

ifyin

g qu

arte

rs

Ente

red

on o

r afte

r 8/

22/9

6 Ye

s

Yes,

afte

r 5

year

s in

US

in a

qu

alifi

ed s

tatu

s

Yes

Paro

lee

(for l

ess

than

on

e ye

ar)

T

I-94

with a

nnota

tio

n “

Paro

led p

urs

uant

to

Sec

tion

212(

d)(5

)” or

“paro

le”

or

“PIP

”

or

I-688

B c

oded

274

a.12

(a)(4

) or 2

74a1

2(c)

(1

1)

or

I-766

cod

ed A

4 or

C11

NA

Ye

s N

o Ye

s N

o

Nor

th A

mer

ican

Indi

an

born

in C

anad

a

To b

e de

term

ined

(P

A)

C

(MA)

I-551

: (P

erm

anen

t Res

iden

t Car

d): s

tam

ped

“S1-3

” , t

empo

rary

I-55

1 st

amp

in a

C

anad

ian

pass

port

or

I-94:

sta

mped “

S1

-3”

or

Trib

al d

ocum

ent c

ertif

ying

at l

east

50%

Am

eric

an In

dian

blo

od, a

s re

quire

d by

S

ectio

n 28

9 of

the

INA

or d

ocum

ente

d m

embe

r of a

fede

rally

reco

gniz

ed tr

ibe

an

d

S

choo

l rec

ords

,

o

r

A b

irth

or b

aptis

mal

cer

tific

ate

issu

ed o

n a

rese

rvat

ion,

or

O

ther

sat

isfa

ctor

y ev

iden

ce o

f birt

h in

C

anad

a

NA

Ye

s

1 R

EMIN

DER

: For

Med

icai

d. u

ndoc

umen

ted

alie

ns a

nd te

mpo

rary

non

-imm

igra

nts

may

rece

ive

cove

rage

for c

are

and

serv

ices

nec

essa

ry fo

r the

trea

tmen

t of e

merg

en

cy m

edic

al c

ondi

tions

onl

y,

not

incl

udin

g ca

re a

nd s

ervi

ces

rela

ted

to a

n or

gan

tran

spla

nt p

roce

dure

, if

othe

rwis

e el

igib

le.

Pre

gnan

t w

omen

may

be

prov

ided

Med

icai

d at

an

y t

ime w

ithou

t re

gard

to

alie

n st

atus

, if

othe

rwis

e el

igib

le. C

hild

ren

may

be

prov

ided

med

ical

ass

ista

nce

with

out r

egar

d to

imm

igra

tion

stat

us u

nder

Chi

ld H

ealth

Plu

s (C

H P

lus)

pro

gram

.

4 Fo

r a V

ictim

of H

uman

Tra

ffick

ing,

EN

TRY

mea

ns th

e da

te o

f Cer

tific

atio

n by

the

Offi

ce o

f Ref

ugee

Res

ettle

men

t (O

RR

) – S

ee 0

3 AD

M-1

.

LDSS

-457

9 (R

ev. 8

/12)

A

LIEN

ELI

GIB

ILIT

Y D

ESK

AID

Pa

ge 7

D

escr

iptio

n of

Sta

tus

WM

S/

ACI

Cod

e C

omm

on D

ocum

enta

tion

R

elev

ant D

ate

for

Elig

ibili

ty

M

edic

aid

1

Fa

mily

Ass

ista

nce

Safe

ty N

et

Assi

stan

ce

SNAP

B

enef

its

Mem

ber o

f fed

eral

ly

reco

gniz

ed tr

ibe

born

ou

tsid

e U

.S.

To b

e de

term

ined

(P

A)

C (M

A)

Mem

bers

hip

card

or o

ther

trib

al

docu

men

t dem

onst

ratin

g m

embe

rshi

p in

a fe

dera

lly

reco

gniz

ed In

dian

trib

e un

der

Sec

tion

4(e)

of t

he In

dian

Sel

f-D

eter

min

atio

n an

d E

duca

tion

Ass

ista

nce

Act

NA

Ye

s

PRU

CO

L (n

ot in

any

of

abov

e st

atus

es)

O (P

A &

M

A)

See

GIS

07

TA/D

C00

1 S

ee O

MM

04

AD

M-7

AN

D

07 O

HIP

INF-

2 N

A

Yes5

No5

Yes5

No

Und

ocum

ente

d im

mig

rant

s or

non

-im

mig

rant

s (a

liens

w

ith a

tem

pora

ry

imm

igra

tion

stat

us)

E

NA

Tr

eatm

ent o

f em

erge

ncy

med

ical

con

ditio

n on

ly1

No

1 R

EMIN

DER

: For

Med

icai

d, u

ndoc

umen

ted

alie

ns a

nd te

mpo

rary

non

-imm

igra

nts

may

rece

ive

cove

rage

for c

are

and

serv

ices

nec

essa

ry fo

r the

trea

tmen

t of e

mer

genc

y m

edic

al c

ondi

tions

on

ly, n

ot in

clud

ing

care

and

ser

vice

s re

late

d to

an

orga

n tr

ansp

lant

pro

cedu

re, i

f oth

erw

ise

elig

ible

. Pr

egna

nt w

omen

may

be

prov

ided

Med

icai

d at

any

tim

e w

ithou

t reg

ard

to a

lien

stat

us, i

f ot

herw

ise

elig

ible

. C

hild

ren

may

be

prov

ided

med

ical

ass

ista

nce

with

out r

egar

d to

imm

igra

tion

stat

us u

nder

Chi

ld H

ealth

Plu

s (C

H P

lus)

pro

gram

. 5

PRU

CO

L re

fers

to a

liens

who

are

per

man

ently

resi

ding

in th

e U

S un

der C

olor

of L

aw.

OT

DA

’s a

nd

the

Dep

art

men

t o

f H

ealt

h’s

(D

OH

) in

terp

reta

tio

n o

f P

RU

CO

L i

s d

iffe

ren

t. A

des

crip

tion

of

TA P

RU

CO

L ca

n be

foun

d in

GIS

07

TA/D

C00

1. A

des

crip

tion

of M

A PR

UC

OL

can

be fo

und

in O

MM

04

ADM

-7 a

nd 0

7 O

HIP

INF-

2.

U

nite

d St

ates

Citi

zens

hip

and

Imm

igra

tion

Serv

ices

(USC

IS –

For

mer

ly IN

S) D

ocum

ents

I-9

4

Arr

ival

/Dep

artu

re R

ecor

d I-5

71

Ref

ugee

Tra

vel D

ocum

ent

I-130

P

etiti

on fo

r an

Alie

n R

elat

ive

I-688

Te

mpo

rary

Res

iden

t Car

d

I-181

M

emor

andu

m o

f C

reat

ion

of R

ecor

d of

Law

ful P

erm

anen

t Res

iden

ce

I-688

A E

mpl

oym

ent A

utho

rizat

ion

For L

egal

izat

ion

App

lican

ts

I-327

R

eent

ry P

erm

it of

Per

man

ent R

esid

ents

I-6

88B

Em

ploy

men

t Aut

horiz

atio

n C

ard

I-360

S

peci

al Im

mig

rant

Pet

ition

I-7

66

Em

ploy

men

t Aut

horiz

atio

n C

ard

I-485

A

pplic

atio

n to

Reg

iste

r Per

man

ent R

esid

ence

or t

o A

djus

t Sta

tus

I-7

97

Not

ice

of A

ctio

n (1

-797

C c

urre

nt v

ersi

on)

I-551

L

eg

al P

erm

an

en

t R

esid

en

t C

ard

, R

esid

ent

Alie

n C

ard

or

“gre

en

ca

rd”

Foot

note

s fo

r Pag

es 4

and

Pag

e 5

3 Th

ere

are

four

requ

irem

ents

for q

ualif

ied

batte

red

alie

n st

atus

:

1.

Be

a cr

edib

le v

ictim

of b

atte

ry o

r ext

rem

e cr

uelty

; an

d

2.

Hav

e ap

prop

riate

imm

igra

tion

docu

men

tatio

n;

a

nd

3.

Be

able

to s

how

a s

ubst

antia

l con

nect

ion

betw

een

the

need

for b

enef

its a

nd th

e ba

ttery

or e

xtre

me

crue

lty;

and

4.

N

o lo

nger

resi

de in

the

sam

e ho

useh

old

as th

e ab

user

.

Appendix I – Work Rules Desk Guide

Prep

ared

by

Hun

ger S

olut

ions

New

Yor

k U

pdat

ed S

epte

mbe

r 201

5

SNA

P W

ork

Rul

es D

esk

Gui

de

Gen

eral

rule

: A

dults

mus

t agr

ee to

look

for w

ork

or p

artic

ipat

e in

SN

AP

Em

ploy

men

t and

Tra

inin

g (E

T) a

ctiv

ities

unl

ess

they

are

EXE

MPT

from

the

wor

k ru

les.

See

OTD

A E

mpl

oym

ent P

olic

y M

anua

l for

spe

cific

rule

s an

d po

licie

s.

W

ho is

exe

mpt

from

the

wor

k ru

les?

√ c

hild

ren

ages

1-1

5

√ a

nyon

e 60

or o

lder

√

som

eone

phy

sica

lly o

r

√ s

omeo

ne c

ompl

ying

men

tally

una

ble

to w

ork

w

/ TAN

F w

ork

rule

s**

√ h

ouse

hold

(hh)

mem

ber c

arin

g

√ p

erso

n re

ceiv

ing

fo

r dep

ende

nt c

hild

und

er 6

Une

mpl

oym

ent

o

r for

a d

isab

led

pers

on

Ins

uran

ce B

enef

its**

(un

less

hh

rece

ives

TAN

F)**

√

reg

ular

par

ticip

ant i

n √

em

ploy

ed o

r sel

f-em

ploy

ed

dr

ug/a

lcoh

ol re

hab*

*

wor

king

at l

east

30

hrs/

wk

OR

with

gro

ss w

eekl

y ea

rnin

gs

√ a

stu

dent

enr

olle

d in

o

f at l

east

$21

7.50

(fed

eral

hig

her e

duca

tion

at

m

inim

um w

age

mul

tiplie

d by

le

ast h

alf-t

ime

(mus

t

30

hour

s)**

als

o m

eet s

tude

nt

ru

les

wor

k av

erag

e of

√

a jo

int a

pplic

ant f

or S

NAP

/SSI

20

hrs/

wk,

etc

.)**

(u

ntil

such

tim

e th

at th

e

p

erso

n is

det

erm

ined

to b

e √

age

16

or 1

7 AN

D

inel

igib

le fo

r SSI

& a

new

wor

k

(

1) n

ot th

e he

ad o

f

sta

tus

rede

term

inat

ion

is m

ade)

.

hou

seho

ld O

R (2

)

a

ttend

ing

scho

ol/

t

rain

ing

at le

ast

**Se

e O

TDA

empl

oym

ent m

anua

l,

h

alf-t

ime.

Sec

tion

3, fo

r mor

e de

tails

.

Wha

t typ

es o

f ET

activ

ities

can

be

assi

gned

?

Eac

h lo

cal d

istri

ct’s

em

ploy

men

t pla

n de

scrib

es th

eir

parti

cula

r ET

activ

ities

, whi

ch c

an in

clud

e:

√

job

sear

ch re

quire

men

ts

√ jo

b se

arch

trai

ning

√ w

ork

expe

rienc

e or

wor

kfar

e

√

job

train

ing

cour

ses

√ e

duca

tiona

l pro

gram

s

√ s

elf-e

mpl

oym

ent p

rogr

ams

How

Man

y Ho

urs

Can

a P

erso

n B

e As

sign

ed to

ET

Activ

ities

?

√ fo

r wor

k ex

perie

nce

(wor

kfar

e): #

of

h

ours

per

mon

th c

anno

t exc

eed

the

val

ue o

f hou

seho

ld’s

ben

efits

(or

TA

/SN

AP) a

llotm

ent d

ivid

ed b

y

m

inim

um w

age

√

tota

l # o

f ET

hour

s ca

nnot

exc

eed

1

20 p

er m

onth

per

indi

vidu

al

W

hat h

appe

ns if

som

eone

doe

sn’t

com

ply

with

ET

requ

irem

ents

?

Indi

vidu

als

who

fail

to c

ompl

y w

ith E

T re

quire

men

ts w

ithou

t goo

d ca

use

(a v

alid

re

ason

) can

be

sanc

tione

d (m

ade

inel

igib

le fo

r a s

peci

fied

leng

th o

f tim

e).

√

ET

sanc

tions

dis

qual

ify o

nly

the

ind

ivid

ual,

not t

he w

hole

hou

seho

ld

√ F

or a

firs

t san

ctio

n, in

elig

ibilit

y la

sts

f

or 2

mon

ths

(60

days

for a

pplic

ants

)

and

unt

il th

e pe

rson

agr

ees

to

c

ompl

y.

√ S

ee O

TDA

man

ual f

or g

ood

caus

e

e

xam

ples

& m

ore

info

on

sanc

tions

.

Wha

t is

a vo

lunt

ary

quit?

“V

olun

tary

qui

t” ge

nera

lly m

eans

“I c

hose

to

qui

t my

job.

” S

ome

situ

atio

ns in

volv

ing

volu

ntar

y qu

its w

ithou

t goo

d ca

use

can

resu

lt in

san

ctio

ns, a

s w

ell a

s so

me

situ

atio

ns w

here

a p

erso

n vo

lunt

arily

re

duce

s hi

s/he

r wor

k ho

urs.

Who

can

be

sanc

tione

d fo

r a

volu

ntar

y qu

it?

√

som

eone

wor

king

30

or m

ore

hour

s/w

eek

OR

ear

ning

at l

east

$21

7.50

/wee

k

who

qui

ts a

job

with

out g

ood

caus

e

√ s

omeo

ne w

orki

ng 3

0+ h

ours

/wee

k w

ho

v

olun

taril

y re

duce

s hi

s/he

r wor

k ho

urs

w

ithou

t goo

d ca

use,

if th

e pe

rson

’s

e

arni

ngs

fall

belo

w $

217.

50/w

eek

Volu

ntar

y qu

it sa

nctio

ns s

houl

d ne

ver b

e im

pose

d on

any

one

who

:

√ i

s la

id o

ff or

fire

d (fo

r any

reas

on)

√ w

orke

d le

ss th

an 3

0 hr

s/w

eek

prio

r to

q

uitti

ng, u

nles

s th

e pe

rson

ear

ned

mor

e

tha

n 21

7.50

/wee

k gr

oss

√

wor

ked

less

than

30

hour

s/w

eek

prio

r

to

redu

cing

thei

r hou

rs

√ r

educ

ed h

is/h

er h

ours

bel

ow 3

0 bu

t stil

l

ear

ns a

t lea

st $

217.

50/w

eek

gros

s

√ h

ad b

een

self-

empl

oyed

√

res

igne

d at

the

empl

oyer

’s d

eman

d √

was

exe

mpt

from

the

wor

k ru

les

at

t

ime

of jo

b qu

it (e

xcep

t for

F/T

em

ploy

men

t exe

mpt

ion)

Fo

r app

lican

ts:

volu

ntar

y qu

it sa

nctio

ns ru

n fro

m a

pplic

atio

n da

te; l

ook

back

per

iod

is 3

0 da

ys; s

anct

ions

cou

nted

in d

ays,

not

mon

ths.

See

othe

r sid

e fo

r AB

AWD

rule

s

Prep

ared

by

Hun

ger S

olut

ions

New

Yor

k U

pdat

ed S

epte

mbe

r 201

5

Able

-Bod

ied

Adul

ts W

ithou

t Dep

ende

nts

(AB

AWD

s)

C

urre

ntly

all

dist

ricts

, inc

ludi

ng N

YC, h

ave

wai

ved

the

AB

AWD

requ

irem

ents

unt

il af

ter D

ecem

ber 3

1, 2

015.

B

egin

ning

Jan

uary

1st

, 201

6 m

any

coun

ties

will

nee

d to

re

inst

ate

the

time

limits

for m

any

child

less

, une

mpl

oyed

ad

ults

. AB

AWD

= a

ge 1

8-49

no c

hild

und

er 1

8 in

SN

AP h

ouse

hold

not d

isab

led

no

t pre

gnan

t

not e

xem

pt fr

om w

ork

rule

s

ABAW

Ds

can

only

get

SN

AP fo

r 3 m

onth

s in

a 3

6-m

onth

per

iod

unle

ss th

ey a

re:

√ w

orki

ng 8

0 ho

urs/

mon

th o

r mor

e; o

r √

in

wor

k pr

ogra

m fo

r 20

hour

s/w

eek;

or

√ c

ompl

ying

with

wor

kfar

e; o

r √

loc

al d

istri

ct a

ccep

ted

wai

ver*

*; or

√

dis

trict

gra

nts

indi

vidu

al e

xem

ptio

n.**

**

NYS

Offi

ce o

f Tem

pora

ry a

nd D

isab

ility

Assi

stan

ce

rele

ases

an

annu

al li

stin

g of

dis

trict

s pr

ovid

ing

wai

vers

a

nd/o

r ind

ivid

ual e

xem

ptio

ns.

The

NYS

OTD

A Em

ploy

men

t Pol

icy

Man

ual is

acc

essi

ble

onlin

e at

:

http

://ot

da.n

y.go

v/re

sour

ces/

empl

oym

ent-m

anua

l/em

ploy

men

tman

ual.p

df

Hun

ger S

olut

ions

New

Yor

k w

ill pr

ovid

e ad

ditio

nal in

form

atio

n on

the

re-

inst

atem

ent o

f the

tim

e lim

its in

NYS

as

polic

y in

form

atio

n fro

m O

TDA

is re

leas

ed.

Plea

se c

heck

our

web

site

for p

olic

y up

date

s, n

ew re

sour

ces

and

to re

gist

er fo

r up

com

ing

web

inar

s

Appendix J –

Categorical Eligibility Desk Guide

Hunger Solutions New York,

September 2015

Expanded Categorical Eligibility Desk Guide:

Hh WITH a senior or disabled member

Hh WITH a senior or

disabled member

which does not pass

the 200% GIT

Hh WITH Dependent

Care Costs

All other Households

If Hh Passes following

Gross Income Test *

200%

N/A

200%

130%

Are they Categorically Eligible for

SNAP

YES

NO

YES

YES

Must meet resource limit

NO YES NO NO

Must meet 100% Net

Income Test

NO YES NO NO

Note: if someone in the household has been disqualified from SNAP due to an intentional program violation or

other sanction, the household is not categorically eligible for SNAP and must instead be evaluated under regular

SNAP eligibility rules.

*Court ordered child support paid by a household member is always deducted from the household’s gross income

before applying the gross income test.

Poverty Guidelines Chart

Family Size 130% of Poverty Monthly Income

Oct. 1, 2015 – Sept. 30 2016

200% of Poverty Monthly Income

Oct. 1, 2015 – Sept. 30, 2016

1 $1,276 $1,962 2 $1,726 $2,655 3 $2,177 $3,348 4 $2,628 $4,042 5 $3,078 $4,735 6 $3,529 $5,428 7 $3,980 $6,122 8 $4,430 $6,815

Each Additional Person

+ $451 + $693

Hunger Solutions New York,

September 2015

Determining a Household’s Categorical Eligibility for SNAP

No Yes No Yes

No Yes No Yes

* Court ordered child support paid by a household member is always deducted from the household’s gross income before applying the

gross income test.

** Households that are not categorically eligible can still qualify for SNAP, but they must be evaluated under regular SNAP rules.

*** Senior and Disabled households that do not pass the 200% GIT may still be eligible for SNAP. See last box above.

NOT Categorically

Eligible**

Is any member of the household a senior or person with disabilities?

OR

Does the Household pay any out-of-pocket dependent care costs?

Is any member of

the household

currently

disqualified from

FSP due to an

Intentional Program

Violation (IPV) or

sanction?

Do not consider

Household’s Resources

Do not apply

Net Income Test

NOT Eligible for

SNAP

NOT Categorically

Eligible**

***Senior/Disabled Hh

See last box in last

column

Is the household’s gross monthly income at or

below the 130% Federal Poverty Level?*

Is the household’s gross monthly income at or

below the 200% Federal Poverty Level?*

Categorically

Eligible

Is any member of

the household

currently

disqualified from

FSP due to an

Intentional Program

Violation (IPV) or

sanction?

Categorically

Eligible

NOT Categorically

Eligible**

Do not consider

Household’s Resources

Do not apply

Net Income Test

Resource Limit

required

Net Income Test

required

***ONLY

For senior/disabled Hh Resource Limit

required

Net Income Test

required

Yes No

Appendix K –

Budget Worksheet

Supplemental Nutrition Assistance Program Budget Worksheet Effective 10/1/15 through 9/30/16

INCOME 1 Gross Monthly Earned Income ____________________

2 Monthly Unearned Income ____________________

3 Gross Income (Line 1 + Line 2) ____________________

4 Child support paid ____________________

5 Adjusted Gross income (Line 3 - Line 4) ____________________ (cannot exceed 130% Gross Income Limit

UNLESS there is an elderly/disabled person or household incurs dependent care costs then use 200%Gross Income Limit)

DEDUCTIONS 6 Earned Income deduction (Line 1 x 20%) ____________________

7 Standard deduction (see chart) ____________________

8 Dependent care (use actual costs) ____________________

9 Homeless deduction ($143) ____________________

10 Medical expenses over $35/month* ____________________

11 Total deductions (Add Lines 6 thru 10) ____________________

12 Adjusted Income (Line 5 – Line 11) ____________________ If the amount is a negative number, enter $0

SHELTER 13 Rent/Mortgage ____________________ EXPENSES

14 Standard utility allowance (SUA) ____________________

15 Other shelter (taxes, etc.) ____________________

16 Total shelter expenses (13+14+15) ____________________

EXCESS 17 Divide line 12 (adjusted income) by 2 ____________________ SHELTER DEDUCTION 17a Shelter Excess (Line 16- Line 17): ____________________

If the amount is greater than $504 enter $504 on 17a -- UNLESS there is an elderly/disabled household member (in which case enter the full amount). If the amount is a negative number, enter $0.

CALCULATING 18 Net Income (Line 12 - Line 17a) ____________________ THE BENEFIT cannot exceed Net Income Limit unless categorically eligible ALLOTMENT (negative number = $0 net income) 19 Thrifty Food Plan amount ____________________

20 Net Income (Line 18) multiplied by 30% ____________________

21 Estimated Benefit (Line 19 - Line 20)** & *** ____________________

*Medical deduction available ONLY to elderly/disabled household members

**ALL 1-2 person households, who pass the net income test or who are categorically eligible, automatically receive a minimum $16 allotment, even if Line 21 is less than $16. ***Categorically eligible households with 3 or more members who yield a zero or negative monthly SNAP benefit (line 21) will NOT be eligible for SNAP.

2

Poverty Guidelines Chart

165% of poverty is used for severely disabled and elderly people who live with others and are unable to purchase and prepare their own food. See page 33 of the Prescreening Guide for more information:

Each Additional H.H. Size 1 2 3 4 5 6 7 8 Person

165% of FPL $1,619 $2,191 $2,763 $3,335 $3,907 $4,479 $5,051 $5,623 +$572

Standard Deduction Amounts

(October 1, 2015 - September 30, 2016):

Household size 1-3 people 4 people 5 people 6 or more people $155 $168 $197 $226

Standard Utility Allowances for NYS (Oct. 1, 2015 - Sept. 30, 2016)

Level 1 Level 2 Level 3 (telephone) New York City $768 $304 $33 Nassau & Suffolk Counties $716 $281 $33 Rest of State $636 $257 $33

MAXIMUM SNAP (Thrifty Food Plan) ALLOTMENTS, by household size

For each

H.H. Size 1 2 3 4 5 6 7 8 Additional Person Maximum $194 $357 $511 $649 $771 $925 $1,022 $1,169 + $146 Allotment

Family Size

130% of Poverty Monthly GROSS Income

10/1/15– 9/30/16

200% of Poverty Monthly GROSS

Income 10/1/15 – 9/30/16

100% of Poverty Monthly NET Income

10/1/15 – 9/30/16

1 $1,276 $1,962 $981 2 $1,726 $2,655 $1,328 3 $2,177 $3,348 $1,675 4 $2,628 $4,042 $2,021 5 $3,078 $4,735 $2,368 6 $3,529 $5,428 $2,715 7 $3,980 $6,122 $3,061 8 $4,430 $6,815 $3,408

Each Additional

Person

+ $451 + $693 + $347

Appendix L –

Checklist for Student Eligibility

Prepared by Hunger Solutions New York Updated September 2015

Checklist for Student SNAP Eligibility Step 1. Establish applicant’s status as a student:

______ The applicant is enrolled in higher education institution that normally requires a high school diploma or equivalency certificate for enrollment. This includes (but is not limited to) colleges*, universities*, correspondence school or online courses, vocational and trade/technical schools at the post-high school level. * Colleges or Universities that offer degree programs regardless of whether a high school diploma is required are also considered Institutions of Higher Education. ______The applicant is enrolled at least half-time (using the school’s definition of half- time). For applicants applying between semesters: ______ The applicant intends to register for the next school term. If checked ‘YES’ to ALL of the above, the applicant is considered a student and the student rule applies - proceed to Step 2. If checked ‘NO’ to ANY ONE of the above, the applicant is NOT considered a student and the student rules do not apply (continue to screen applicant under regular SNAP rules). Step 2. Is the student enrolled in a college meal plan?

______The student receives 50% or more of their meals from a college meal plan. If checked ‘YES’ to above, the student is NOT eligible for SNAP as he/she is considered to be defined as living in an institution. If checked ‘NO’, continue to Step 3. If the student meets ANY ONE of the exemptions below, the student is eligible for SNAP and can be included in the SNAP household. The income of the student will be used in determining eligibility for the household. Step 3. Does the student meet ANY of the following exemptions?

Individual Characteristics ______ 17 years of age and under or 50 years of age and over. ______ Mentally or physically unfit under ET or ABAWD rules to work. ______ Primary caretaker for a household member who is under 6 or is incapacitated. ______ Primary caretaker for a household member between the ages of 6 and 11, if no

adequate child care is available that would make it possible to work and go to school**.

______ Is a single parent enrolled full-time who is responsible for the care of a child under 12. Student Is Working ______ Works an average of 20 hours per week. ______ Is self-employed an average of 20 hours/week and receives average weekly earnings at least equal to the federal minimum wage multiplied by 20 hours.

______ Participates in work-study (even if it is less than 20 hours/week). Student Participates in a Qualifying Government Program ______ Is a TANF recipient (and is complying with the TANF work rules). ______ Is required to attend school by the SNAP employment and training program, or a similar program operated by a state or local government. ______ Student is attending school through unemployment (Department of Labor). For additional information on Student Eligibility consult Hunger Solutions New York's SNAP Eligibility Guide, under status-based limitations.

Appendix M –

Household Composition Desk Guide (LDSS 4314)

LDSS

-431

4 (R

ev. 8

/12)

SUPP

LEM

ENTA

L N

UTR

ITIO

N A

SSIS

TAN

CE

PRO

GR

AM

(SN

AP)

BEN

EFIT

S H

OU

SEH

OLD

CO

MPO

SITI

ON

DES

K G

UID

E A

ll pe

rson

s, e

ven

if th

ey a

re m

embe

rs o

f diff

eren

t fam

ilies,

who

cus

tom

arily

pur

chas

e an

d pr

epar

e m

eals

toge

ther

are

to b

e co

nsid

ered

m

embe

rs o

f the

sam

e S

NA

P b

enef

its h

ouse

hold

.

REL

ATI

ON

SHIP

S:

SIT

UA

TIO

N R

ES

UL

T

Spou

ses

Livi

ng T

oget

her

Mus

t alw

ays

be c

onsi

dere

d as

a s

ingl

e ho

useh

old.

Pare

nts

and

thei

r Chi

ldre

n, 2

1 Ye

ars

of A

ge o

r You

nger

, Li

ving

Tog

ethe

r (In

clud

es S

tepc

hild

ren)

rega

rdle

ss o

f w

heth

er th

e ch

ildre

n ha

ve a

spo

use

or c

hild

ren

of th

eir

own.

Mus

t be

cons

ider

ed a

s a

sing

le h

ouse

hold

.

Chi

ldre

n U

nder

18

(Exc

ept F

oste

r Chi

ldre

n)

Und

er th

e Pa

rent

al C

ontro

l of a

n Ad

ult H

ouse

hold

Mem

ber

Who Is N

ot th

e C

hild

ren’s

Pare

nt or

Ste

ppare

nt.

Mus

t be

cons

ider

ed a

s a

sing

le h

ouse

hold

.

(Rem

ind

er:

A c

hild

und

er 1

8 liv

ing

with

thei

r spo

use

or c

hild

is n

ot c

onsi

dere

d un

der p

aren

tal

cont

rol.)

NO

TE:

Ther

e is

no

age

requ

irem

ent f

or a

n in

divi

dual

not

und

er p

aren

tal c

ontro

l to

rece

ive

SNAP

ben

efits

.

CIR

CU

MST

AN

CES

CA

USI

NG

INEL

IGIB

ILIT

Y:

SIT

UA

TIO

N R

ES

UL

T

Res

iden

t of I

nstit

utio

n In

elig

ible

unl

ess

a re

side

nt o

f a:

Dru

g/al

coho

l Tre

atm

ent f

acilit

y S

ubsi

dize

d ho

usin

g fo

r the

eld

erly

S

helte

r for

the

hom

eles

s

Cer

tain

gro

up li

ving

arr

ange

men

t S

helte

r for

bat

tere

d w

omen

and

chi

ldre

n

Inel

igib

le S

tude

nt

Non

-hou

seho

ld m

embe

r. (In

com

e an

d re

sour

ces

are

excl

uded

. The

hou

seho

ld c

an c

laim

th

eir p

rora

ted

shar

e of

exp

ense

s.)

Wor

k R

ules

San

ctio

ned

or In

tent

iona

l Pro

gram

Vi

olat

ion

Dis

qual

ified

Ex

clud

ed h

ouse

hold

mem

ber.

(Inco

me

and

reso

urce

s ar

e co

unte

d in

thei

r ent

irety

. The

ho

useh

old

can

clai

m fu

ll ex

pens

es.)

Any

indi

vidu

al w

ho is

inel

igib

le to

get

a S

ocia

l Se

curit

y N

umbe

r, or

any

indi

vidu

al w

ho if

una

ble

to

prov

ide

a S

SN, f

ails

to a

pply

for a

SS

N o

r ref

uses

to c

oope

rate

with

reso

lvin

g a

SSN

va

lidat

ion

disc

repa

ncy.

Excl

uded

hou

seho

ld m

embe

r. (In

com

e is

pro

rate

d; re

sour

ces

are

coun

ted

in th

eir e

ntire

ty.

Expe

nses

pai

d by

or b

illed

to th

e ex

clud

ed p

erso

n ar

e pr

orat

ed.

An in

divi

dual

who

fails

to p

rovi

de o

r app

ly fo

r a S

ocia

l Se

curit

y N

umbe

r (SS

N),

or a

ny in

divi

dual

who

if

unab

le to

pro

vide

a S

SN, f

ails

to a

pply

for a

SSN

Excl

uded

hou

seho

ld m

embe

r. (I

ncom

e is

pro

rate

d; re

sour

ces

are

coun

ted

in th

eir e

ntire

ty.

Expe

nses

pai

d by

or b

illed

to th

e ex

clud

ed p

erso

n ar

e pr

orat

ed.)

App

lyin

g fo

r or p

rovi

ding

th

e SS

N im

med

iate

ly b

rings

the

excl

uded

indi

vidu

al in

to c

ompl

ianc

e.

A ho

useh

old

that

fails

to o

r ref

uses

to c

oope

rate

in

the

SSN

val

idat

ion

proc

ess.

Th

e SN

AP c

ase

is c

lose

d.

LDSS

-431

4 (R

ev. 8

/12)

SUPP

LEM

ENTA

L N

UTR

ITIO

N A

SSIS

TAN

CE

PRO

GR

AM

(SN

AP)

BEN

EFIT

S H

OU

SEH

OLD

CO

MPO

SITI

ON

DES

K G

UID

E P

erso

ns re

sidi

ng to

geth

er w

ho d

o no

t mee

t any

of t

he p

revi

ous

defin

ition

s m

ay b

e se

para

te h

ouse

hold

s if

they

pur

chas

e an

d pr

epar

e fo

od

sepa

rate

ly fr

om th

e ot

her p

erso

ns.

SPEC

IAL

LIVI

NG

AR

RA

NG

EMEN

T:

SIT

UA

TIO

N R

ES

UL

T

Boar

der (

Roo

m a

nd M

eals

) N

ot a

par

t of t

he h

ouse

hold

, but

may

be

cons

ider

ed to

be

a m

embe

r of a

hou

seho

ld a

t the

h

ou

seh

old

’s r

eq

uest.

May

nev

er b

e a

sepa

rate

hou

seho

ld. T

he fo

llow

ing

can

neve

r be

cons

ider

ed b

oard

ers:

Pare

nts

and

child

ren,

age

21

and

youn

ger w

ho li

ve to

geth

er.

A

spou

se o

f a m

embe

r of t

he h

ouse

hold

.

Chi

ldre

n un

der 1

8 ye

ars

of a

ge w

ho a

re u

nder

the

pare

ntal

con

trol o

f an

adul

t m

embe

r of t

he h

ouse

hold

incl

udin

g a

sibl

ing.

Roo

mer

(Roo

m, N

o M

eals

) N

ot c

onsi

dere

d pa

rt of

hou

seho

ld, b

ut m

ay a

pply

as

a se

para

te h

ouse

hold

.

Shar

ed L

ivin

g (P

ays

a Sh

are

of S

helte

r Exp

ense

s)

Not

con

side

red

part

of h

ouse

hold

, but

may

app

ly a

s a

sepa

rate

hou

seho

ld.

Elde

rly In

divi

dual

s an

d th

eir S

pous

es

Sepa

rate

hou

seho

ld s

tatu

s m

ay b

e gr

ante

d to

thos

e el

derly

indi

vidu

als

and

thei

r spo

use

who

can

not p

urch

ase

and

prep

are

thei

r ow

n m

eals

bec

ause

they

suf

fer f

rom

cer

tain

di

sabi

litie

s, e

ven

if th

ey a

re li

ving

and

eat

ing

with

oth

ers,

if th

ey m

eet c

erta

in c

ondi

tions

.*

Fost

er C

hild

ren

It is t

he h

ou

seh

old

’s d

ecis

ion t

o inclu

de

or

exclu

de

fost

er c

hild

ren

as h

ouse

hold

mem

bers

. If

incl

uded

, tho

se fo

ster

car

e pa

ymen

ts th

at c

anno

t be

excl

uded

as

verif

ied

reim

burs

emen

ts

are

coun

ted

as in

com

e. I

f exc

lude

d, th

e fo

ster

car

e pa

ymen

ts a

re n

ot c

ount

ed a

s in

com

e.

*ALL

OF

THE

FOLL

OW

ING

CO

ND

ITIO

NS

MU

ST B

E M

ET:

Th

e in

divi

dual

mus

t be

60 y

ears

of a

ge o

r old

er; a

nd

Th

e in

divi

dual

mus

t suf

fer f

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Appendix N –

Authorized Representative Request Form

(LDSS-4942)

LDSS-4942 (Rev. 8/12) NYSOTDA

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

AUTHORIZED REPRESENTATIVE REQUEST FORM

Applicant Name:

Applicant Address:

Applicant Number:

AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to apply for SNAP benefits for you. You can also authorize someone to use your SNAP benefit to buy food for you. If you would like to authorize someone for either of these purposes, you must do so in writing. You may do so by printing the person’s name, address and phone number below and signing at the bottom of this form.

Authorized Representative Name:

Authorized Representative Address:

Authorized Representative Telephone Number: I authorize the above designated individual to act as my representative for the purposes checked below. I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the functions listed next to the boxes. I understand that I may revoke all or part of this authorization at any time by notifying my local district in writing.

Application for SNAP benefits Please Check the Recertification for SNAP benefits Appropriate Box(es) To use my SNAP benefit (EBT card) to purchase food for me All of the above

SNAP BENEFITS PENALTY WARNING – Any information you provide in connection with your application for SNAP will be subject to verification by Federal, State and local officials. If any information is incorrect, you may be denied SNAP. You may be subject to criminal prosecution for knowingly providing incorrect information. You will never be able to get SNAP benefits again if you are found guilty in a court of law for the second time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP; or found guilty in a court of law of selling or getting firearms, ammunition or explosives in exchange for SNAP; or found guilty in a court of trafficking in SNAP worth $500 or more. Trafficking includes the unauthorized use, transfer, acquisition, alteration or possession of SNAP, authorization cards or access devices; or found guilty of committing a third Intentional Program Violation (IPV). You will not be able to get SNAP for two years if you are found guilty in a court of law for the first time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP. If you have committed your: First IPV, you will not be able to get SNAP for one year. Second IPV, you will not be able to get SNAP for two years. Third IPV, you are permanently disqualified. A court could also bar you from receiving SNAP benefits for an additional 18 months if you are convicted of certain felonies or misdemeaners. If you make a false statement about who you are or where you live in order to get multiple SNAP benefits at the same time, you will not be able to get SNAP for ten years (or permanently if this is the third IPV). You may be found to have committed an IPV if you make a false or misleading statement, or misrepresent, conceal or withhold facts; or commit any act that constitutes a violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of coupons, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system.

You could also be fined up to $250,000, sent to jail for up to 20 years, or both.

Note: Both the applicant and/or authorized representative are subject to the above penalties. Applicant Signature: Date:

As an authorized representative I acknowledge the information set forth above.

Authorized Representative Signature: Date:

LDSS-4942 SP (3/09) NYSOTDA

PROGRAMA DE CUPONES PARA ALIMENTOS FORMULARIO DE PETICIÓN DE REPRESENTANTE AUTORIZADO

Nombre del Solicitante: Domicilio del Solicitante: Número de Teléfono del Solicitante:

REPRESENTANTE AUTORIZADO: usted puede autorizar a alguien familiarizado con las circunstancias de su hogar para que solicite los beneficios de cupones para alimentos (FS) por usted. Usted también puede autorizar a otra persona a utilizar sus beneficios de cupones para alimentos para que dicha persona compre los alimentos por usted. Si desea autorizar a otra persona para que realice uno de esos propósitos, debe hacerlo por escrito. También puede hacerlo escribiendo, a continuación, el nombre, domicilio y número de teléfono de dicha persona y firmando al pie de este formulario.

Nombre de Representante Autorizado:

Domicilio del Representante Autorizado:

Número de Teléfono de Representante Autorizado:

Autorizo a la persona arriba mencionada a que actúe en mi representación para el propósito marcado a continuación. Entiendo que si no marco ninguno de los casilleros a continuación, mi representante autorizado estará autorizado a realizar todas las funciones listadas en los casilleros. Entiendo que puedo revocar parcial o enteramente esta autorización cuando lo decida notificando al respecto y por escrito, al distrito local.

Solicitar los beneficios de Cupones para Alimentos Favor de marcar el / los Revalidar los beneficios de Cupones para Alimentos

casillero(s) apropiados Usar mi Beneficio de Cupones para Alimentos (Tarjeta EBT) para comprar los alimentos por mí.

Todas las anteriores ADVERTENCIA SOBRE SANCIONES RELACIONADAS CON EL PROGRAMA DE CUPONES PARA ALIMENTOS (FS): toda información que brinde en relación con su solicitud para recibir los cupones para alimentos estará sujeta a la verificación por autoridades federales, estatales y locales. De encontrarse información inexacta, se le podrán denegar los cupones. Se le someterá a enjuiciamientos penales por proporcionar, a sabiendas, información incorrecta.

Nunca más podrá obtener beneficios de cupones para alimentos (FS) si se le declara culpable por segunda vez en un tribunal de justicia de comprar o vender sustancias controladas (drogas ilegales o drogas para las cuales se requiere receta médica) a cambio de cupones; o si se le declara culpable en un tribunal de justicia de vender u obtener armas de fuego, municiones o explosivos a cambio de cupones; o si se le declara culpable en un tribunal de justicia de traficar cupones para alimentos por un valor de $500 o más. El tráfico incluye el uso no autorizado la transferencia, la adquisición, la manipulación o la posesión de cupones para alimentos, tarjetas de autorización o elementos de acceso; o si es declarado culpable de cometer la tercera Violación Intencional al Programa (IPV).

No podrá recibir cupones para alimentos durante dos años si se le declara culpable, por primera vez, en un tribunal de justicia de comprar o vender sustancias controladas (drogas ilegales o determinadas drogas que sólo se pueden comprar con receta médica) a cambio de cupones para alimentos. Si ha cometido su: Primera Violación Intencional al Programa, no podrá recibir los cupones para alimentos por un periodo de un año. Segunda Violación Intencional al Programa, no podrá recibir los cupones por un periodo de dos años. Tercera Violación Intencional al Programa, se le negarán permanentemente.

Además, el juez puede prohibirle de recibir los beneficios de Cupones para Alimentos por unos 18 meses adicionales si se le declara culpable de ciertos delitos graves o delitos menores. Si hace una declaración falsa sobre su identidad o domicilio a fin de recibir beneficios múltiples de cupones a la misma vez, no podrá recibir cupones durante un periodo de diez años (o en forma permanente si ésta es su tercera violación intencional al programa). Se le puede declarar culpable de haber perpetrado una violación intencional si presta testimonio falso o engañoso, o hace representaciones falsas, oculta o retiene datos; o comete un acto que constituya una violación de la ley federal o estatal con el propósito de usar, presentar, transferir, adquirir, recibir, poseer o traficar cupones, tarjetas de autorización o documentos reusables pertenecientes al sistema de Transferencia Electrónica de Beneficios (EBT).

Se le puede imponer una multa de hasta $250,000, una pena de prisión de hasta 20 años, o ambas sanciones.

Nota: tanto el solicitante como el representante autorizado estarán sujetos a las sanciones anteriores. Firma del Solicitante: Fecha:

Como representante autorizado, doy fe de lo anterior.

Firma del Representante Autorizado: Fecha:

Appendix O –

Replacement SNAP Benefits Request Form (LDSS-2291)

& Hunger Solutions New York Client-Friendly Cover Sheet

LDSS-2291 (Rev.8/14)

REQUEST FOR REPLACEMENT OF FOOD PURCHASED WITH SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) BENEFITS

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

CASE NAME

COUNTY

CASE NUMBER

SSN DATE OF BIRTH

ADDRESS (including house and Apt number)

CITY STATE ZIP PHONE NUMBER

I ________________________________________, am the head of household or an adult household member for the above named case and wish to report the following to the agency representative: My household experienced a loss in the amount of $ _______________________ of food purchased with Supplemental Nutrition Assistance Program (SNAP) benefits, destroyed as a result of:

A power outage A flood A fire Other disaster Describe: ______________________________________________________________________

Worker Comments: _________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Client Comments: _________________________________________________________________________________

_________________________________________________________________________________________________

CERTIFICATION DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE STATEMENTS BELOW

I am aware that offering a false instrument for filing as described in Article 175 of the Penal Law is a crime that may have a maximum penalty of four (4) year’s imprisonment. If I do so, I will be subject to prosecution under the Civil and Criminal Laws of the United States and New York State and under the regulations of the New York State Office of Temporary and Disability Assistance.

I understand I have a right to a fair hearing to contest the denial or delay of a replacement issuance for my household. Replacements would not be issued pending the fair hearing decision.

I understand that if I do not sign and return this statement to the agency within ten (10) days of the date the loss was reported, the agency will not replace the SNAP benefits.

Signature

Date

*Please return this completed form to your local County Social Service Department (SSD) or for NYC residents visit the HRA website

for a list of the local center closest to you.

LDSS-2291 SP (Rev.8/14)

PETICIÓN DE REEMPLAZO DE ALIMENTOS ADQUIRIDOS CON EL SUBSIDIO DEL PROGRAMA DE ASISTENCIA NUTRICIONAL SUPLEMENTARIA (SNAP)

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

CASO A NOMBRE DE:

CONDADO

Nº DE CASO

Nº DE SEGURO SOCIAL FECHA DE

NACIMIENTO

DIRECCIÓN (incluya el Nº de la casa o del apartamento)

CIUDAD ESTADO CÓDIGO

POSTAL Nº DE TELÉFONO

I ________________________________________, siendo el jefe del hogar o integrante adulto del hogar correspondiente al caso mencionado arriba, deseo informar lo siguiente al representante de la agencia: Mi hogar sufrió una desgracia debido a:

Una interrupción del servicio eléctrico Una inundación Un incendio Otro desastre Describa: ________________________________________________________________

Como resultado se dañaron los alimentos comprados con el subsidio del Programa de Asistencia Nutricional Suplementaria (SNAP) por un valor de $ _______________________ Comentarios del trabajador(a) social: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Comentarios del cliente: ____________________________________________________________________________

______________________________________________________________________________________________

CERTIFICACIÓN NO FIRME HASTA QUE HAYA LEIDO Y COMPRENDIDO LAS DECLARACIONES SIGUIENTES

Estoy consciente que el proveer un instrumento falso para ser archivado en mi caso, tal como lo describe el Artículo 175 de la Ley Penal, es un delito que puede acarrear una pena máxima de cuatro (4) años en prisión. Si lo hago, estaré sujeto(a) a enjuiciamiento bajo las Leyes Civiles y Penales de Estados Unidos y del Estado de Nueva York como también bajo las regulaciones de la Oficina de Asistencia Temporal y Asistencia para Incapacitados del Estado de Nueva York.

Comprendo que tengo el derecho a una audiencia imparcial para cuestionar la negación o el retraso de la emisión de reemplazo de beneficios para mi hogar. Los reemplazos no se emitirán si la decisión de la audiencia imparcial está pendiente.

Comprendo que si yo no firmo y devuelvo esta declaración a la agencia dentro de diez (10) días a partir de la fecha en que se informó la pérdida de mi subsidio SNAP, la agencia no reemplazará mi subsidio SNAP.

*Sírvase regresar este formulario completamente rellenado al departamento local de servicios sociales de su condado (SSD). Para los residentes de

la Ciudad de Nueva York, sírvanse ingresar a la página web de HRA para ver la lista de los centros locales más cercanos a su domicilio.

Firma

fecha

Have you lost food because of an emergency?Do you buy groceries with SNAP? You may be able to get some of your SNAP dollars added back to your EBT card.

WHAT YOU NEED TO KNOW:• If you receive SNAP benefits and you have lost food due to a household

misfortune, you can request replacement SNAP benefits

• The loss can be due to a situation that affects large areas, such as a storm or a flood, or can be specific to a single household, such as a fire

• Household misfortunes can include: Storms Equipment failure (refrigerator or freezer) Flooding Extended power outages Fire Failure to pay a utility bill Note: power must be out for 4 hours or more to be eligible for SNAP replacement

WHAT YOU NEED TO DO:• Fill out and submit a replacement form to your local SNAP/HRA office

within 10 days of the loss. You can do this by mail or in person.

• If you are unable to submit the form within 10 days, call the SNAP/HRA office immediately to verbally report the loss. You will then have 10 days to return the form after you report.

• Your local Nutrition Outreach and Education Program (NOEP) Coordinator can help you report the loss and submit the form. They can also help you obtain the form in other languages if necessary. NOEP Coordinators are community partners who can help with any questions you may have about SNAP. It’s free and confidential.

To find your local NOEP Coordinator, visit FoodHelpNY.org. If there is not a NOEP Coordinator in your county, call to find your local SNAP/HRA office: Outside New York City, dial 800-342-3009 In New York City, dial 311

HungerSolutionsNY.org • FoodHelpNY.org • SummerMealsNY.org • SchoolMealsHubNY.org • AfterschoolMealsNY.org

Prepared by Hunger Solutions New York with support from NYSOTDA, USDA/FNS, FRAC, Walmart Foundation, Share Our Strength, and MAZON: A Jewish Response to Hunger. This institution is an equal opportunity provider.

Appendix P –

Change Report Form (LDSS - 3151)

LDSS-3151 (Rev. 8/12) PAGE 1

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE CASE NUMBER

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) CHANGE REPORT FORM

(Please Print Clearly)

YOU MUST REPORT ANY CHANGES IN YOUR CIRCUMSTANCES DATE: _________________

ACCORDING TO THE RULES LISTED BELOW. COMPLETE THIS FORM AND MAIL TO:

TO:

ADDRESS:

LOCAL DISTRICT NAME, ADDRESS AND TELEPHONE NUMBER:

YOUR RESPONSIBILITY TO REPORT CHANGES

Please read the questions and rules carefully. If you fail to report any changes that you are required to report under the rules, we may have to establish a claim for overpayment of Supplemental Nutrition Assistance Program (SNAP) benefits and collect the amount of the overpayment from you.

The changes that you MUST report are explained below. You may still voluntarily report any change about your SNAP household and, if this change will increase your benefit level and you verify this change, we will increase your benefit. ARE YOU A “SIMPLIFIED REPORTER” (6 MONTH) OR A “CHANGE REPORTER”? YOU MAY ANSWER THESE QUESTIONS TO FIND OUT WHETHER YOU ARE A “SIMPLIFIED REPORTER” OR A “CHANGE REPORTER”.

1. Do you receive transitional SNAP benefits (TBA)?

YES – Go To “TBA” on page 3 (Skip questions 2 through 8)

NO – Go To Question #2, below

2. Do you receive New York State Nutrition Improvement Project (NYSNIP) benefits?

YES – Go To “NYSNIP” on page 3 (Skip questions 3 through 8)

NO – Go To Question #3, below

3. Are you certified for SNAP benefits for three months or less at a time?

YES –Go To “Change Reporting” on

page 2 (Skip questions 4 through 8) NO – Go To Question #4, below

4. Does anyone in your household have earned income that is being counted in your SNAP benefit amount?

YES –Go To “Simplified Reporting”

on page 2 (Skip questions 5 through 8)

NO – Go To Question #5, below

5. Are all of the adults (18 or older) in your household either permanently disabled or 60 or older?

YES –Go To “Change Reporting” on

page 2 (Skip questions 6 through 8) NO – Go To Question #6, below

6. Does your household receive $0 income (including $0 Temporary Assistance)

YES –Go To “Change Reporting” on

page 2 (Skip questions 7 and 8) NO – Go To Question #7, below

7. Are you without shelter (undomiciled) or a migrant/seasonal farmworker?

YES – Go To “Change Reporting”

on page 2 (Skip question 8) NO – Go To #8, below

8. You answered “NO” to all 7 questions

above Go To “Simplified Reporting” on the

top of page 2

PAGE 2 LDSS-3151 (Rev. 8/12)

SIMPLIFIED REPORTING RULES: As a SNAP household under the “Simplified Reporting” rules, you are only required to report

changes at the time of your next recertification, except for the following three situations:

1. If your household’s gross monthly income exceeds 130% of the poverty level, you MUST report this monthly amount to your social services district by telephone, in writing, or in person within 10 days after the end of the calendar month in which you exceed the 130% level. 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 SNAP benefits. Your worker will explain what 130% of the poverty level means for a family of your size. Any other kind of income that you receive besides earnings must be added to your gross earned income to know if you are over 130% of the poverty level. Examples of other sources of income that count include child support you receive, Unemployment Insurance, Temporary Assistance (TA) payments, Workers Compensation, Social Security Benefits, Supplemental Security Income (SSI) and private disability payments.

If you fail to report that your gross income is above 130% of the poverty level in any calendar month, all benefits received after that month may be considered an overpayment. This is true even if your gross income falls below the 130% poverty level in a future month.

2. If your household’s certification period is longer than 6 months: At a six-month checkpoint into your certification period, you will receive a report form that you MUST return within ten days after you receive the form. If your household has any of the changes listed below, you MUST report them on the report form that is sent to you at the six-month checkpoint. List of Changes you must report at the six-month checkpoint:

Changes in any source of income for anyone in your household Changes in your household’s total earned income when it goes up or down by more than $100 a month Changes in your household’s total unearned income from a public source such as Social Security Benefits or

Unemployment Insurance Benefits when it goes up or down by more than $50 a month Changes in your household’s total unearned income from a private source such as Child Support Payments or Private

Disability Insurance when it goes up or down by more than $100 a month Changes in the amount of court ordered child support you pay to a child outside of your SNAP household Changes in who lives with you If you move, your new address and your new rent or mortgage costs, heat costs and utility costs A new or different car, or other vehicle Increases in your household’s cash, stocks, bonds, money in the bank or savings institution if the total cash and

savings of all household members now amounts to more than $2000 (more than $3250 if anyone in your household is disabled or 60 years old or older)

Any changes in your household that would result in a penalty as described on page 6

3. If anyone in your SNAP household is an Able-Bodied Adult Without Dependents (“ABAWD”), you MUST tell us if their work hours go below 80 hours a month within 10 days after the end of that month.

CHANGE REPORTING RULES: As a SNAP household under the “Change Reporting” rules, you MUST report the following changes within 10 days after the end of the month in which the change happened:

Changes in any source of income for anyone in your household Changes in your household’s total earned income when it goes up or down by more than $100 a month Changes in your household’s total unearned income from a public source such as Social Security Benefits or

Unemployment Insurance Benefits when it goes up or down by more than $50 a month Changes in your household’s total unearned income from a private source such as Child Support Payments or Private

Disability Insurance when it goes up or down by more than $100 a month Changes in the amount of court ordered child support you pay to a child outside of your SNAP household Changes in who lives with you If you move, your new address and your new rent or mortgage costs, heat costs and utility costs A new or different car, or other vehicle Increases in your household’s cash, stocks, bonds, money in the bank or savings institution if the total cash and savings

of all household members now amounts to more than $2000 for a household without an elderly or permanently disabled household member or $3250 for a household with an elderly or permanently disabled household member.

If anyone in your SNAP household is an Able-Bodied Adult Without Dependents (“ABAWD”), you must tell us if their work hours go below 80 hours a month within 10 days after the end of that month

Any changes in your household that would result in a penalty as described on page 6

LDSS-3151 (Rev. 8/12) PAGE 3

TBA CHANGE REPORTING for household in receipt of transitional benefits: Transitional SNAP benefits can continue for up to five months after your Temporary Assistance case closes. You are not required to report changes during the transition period. If you have changes that may increase your benefits you

can contact your worker to file an early recertification application at any time during your transitional period to receive the increase. The increase cannot be done until a signed recertification application is filed, and the entire recertification process is completed.

You must recertify near the end of your transitional period to see if you can continue to receive SNAP benefits after your transitional period ends. We will send you a notice reminding you of this recertification requirement. If you do not recertify, we will not send you any other notice and must close your SNAP case.

NYSNIP CHANGE REPORTING for participants in NYSNIP: You will receive a contact letter 24 months after you begin participation in NYSNIP that you must complete and return. You are not required to report changes during your certification period other than the 24-month contact letter. You may

voluntarily report increases in your medical expenses, rent or utility costs, or decreases in your income. If you report and verify these changes, you may be eligible for more SNAP benefits. You are not required to, but should report your new address if you move, so that you continue to receive any notices we send to you.

Medical Expenses: You are not required to report changes in your medical expenses during your certification period. However, you may voluntarily report changes in your medical expenses for household members that are:

- 60 years old or older - getting veterans’ disability benefits - disabled spouses or children of a deceased veteran - getting government disability retirement benefits - getting Supplemental Security Income (SSI) - getting Railroad Retirement disability benefits - getting Social Security Disability payments - getting disability-based medical assistance

If you report and verify an increase in your medical expenses, you may be eligible for more SNAP benefits. Changes in medical expenses must be reported at your next recertification.

Temporary Assistance (TA) Reporting Rules: The rules listed above apply only to SNAP. If you also receive TA, you are still required to report changes for TA within 10 days of the change, on periodic report mailers, TA Eligibility Questionnaires and at recertification.

When to use this form:

This form may be used to report any required or voluntary changes. You can also use this form to report changes in the cost of caring for children or disabled adults, or changes in shelter costs even if you haven’t moved. If these expenses go up you may be eligible for more SNAP benefits.

If proof of the changes you are reporting is available, please include it with this form. This will help make sure that you get the correct amount of SNAP benefits. Reported changes must be verified before we can increase your benefits.

This form should be mailed or brought to the agency listed above. If for some reason you can’t mail or bring in this form, you can report the changes by calling us at the telephone number listed on Page 1.

If you no longer want to receive SNAP benefits, sign here to withdraw from participation in SNAP. Your SNAP benefits will stop. You have the right to contest this withdrawal if you feel that you were given incorrect or incomplete information about your eligibility for SNAP benefits by requesting a Fair Hearing within 90 days. You may re-apply for SNAP benefits at any time after your withdrawal.

X

IF YOU WITHHOLD INFORMATION ABOUT CHANGES IN YOUR HOUSEHOLD THAT YOU ARE REQUIRED TO REPORT, YOU WILL OWE US THE VALUE OF ANY EXTRA SNAP BENEFITS YOU RECEIVE AS A RESULT. IF YOU INTENTIONALLY WITHHOLD INFORMATION WHEN YOU ARE REQUIRED TO REPORT IT, YOU MAY ALSO BE DISQUALIFIED FROM SNAP AND COULD BE SUBJECT TO CRIMINAL PROSECUTION (SEE ATTACHED “SNAP PENALTY WARNING” ON PAGE 6).

PAGE 4 LDSS-3151 (Rev. 8/12)

Use the Form Below to Report Changes CHANGE IN INCOME OR SOURCE OF INCOME – If you are a Simplified Reporter, your reporting rules are explained beginning on Page 2. If you are a Change Reporter, your reporting rules are also explained on Page 2.

NAME OF PERSON RECEIVING INCOME SOURCE OF INCOME NEW AMOUNT HOW OFTEN RECEIVED

1. $

2. $

3. $

CHANGE IN HOUSEHOLD - List below all new members to your household including newborn children. Also list members who have moved in or out or have died.

NAME AGE RELATIONSHIP CHANGE (CHECK ONE) DATE INCOME AMOUNT SOURCE

1. CAME INTO HOUSEHOLD

LEFT HOUSEHOLD $

2. CAME INTO HOUSEHOLD

LEFT HOUSEHOLD $

3. CAME INTO HOUSEHOLD

LEFT HOUSEHOLD $

4. CAME INTO HOUSEHOLD

LEFT HOUSEHOLD $

CHANGE OF ADDRESS NEW MAILING ADDRESS CITY STATE ZIP CODE

IF YOU DON’T HAVE A STREET ADDRESS, GIVE DIRECTIONS TO YOUR HOME (if you are homeless, leave blank) TELEPHONE NUMBER WHERE YOU CAN BE REACHED

( ) AREA CODE

CHANGE IN HOUSING COSTS - If you have moved, you must list your new costs below. Even if you have not moved, you can use this section to tell us that your rent, mortgage payment or other costs have changed.

Are you a roomer or boarder? YES NO If Yes, are meals INCLUDED NOT INCLUDED RENT YES NO IF YES, GIVE MONTHLY AMOUNT CHANGE (CHECK ONE)

Do you pay rent? $ Same More Less Do you pay for the following separate from your rent? YES NO

Heat and/or air conditioning Utilities (electricity, cooking gas, etc.) Telephone

MORTGAGE PAYMENT YES NO IF YES, GIVE MONTHLY AMOUNT CHANGE (CHECK ONE)

Do you have a mortgage payment? $ Same More Less Do you pay for the following separate from your mortgage: YES NO IF YES, GIVE MONTHLY AMOUNT CHANGE (CHECK ONE)

Property taxes $ Same More Less House Insurance $ Same More Less Heat and/or air conditioning Utilities (electricity, cooking gas, etc.) Telephone

Are you living in section 8 or other subsidized housing? YES NO Are you living in public housing? YES NO

LDSS-3151 (Rev. 8/12) PAGE 5

CHANGE IN NUMBER OF CARS OR VEHICLES - Has anyone in your household purchased, sold or traded a car, truck, boat, camper, motorcycle or other vehicle since the last time you told us about vehicles?

MAKE MODEL YEAR IF SOLD, AMOUNT RECEIVED

1. $

2. $

3. $

CHANGE IN SAVINGS - List the total amount of money that the members of your household now have. Include cash, savings accounts, checking accounts, stocks, bonds or other investments. You must tell us if your household savings have increased to more than $2,000 (more than $3,250 if anyone in your household is 60 years old or older or been determined to be disabled).

$

CHANGE IN CHILD CARE, DEPENDENT CARE COSTS OR THE AMOUNT OF CHILD SUPPORT PAID - Have your child care or dependent care costs changed? If so, you may be eligible for more SNAP benefits.

CHANGE (CHECK ONE) FOR WHOM? WHOM DO YOU PAY? NEW AMOUNT HOW OFTEN DO YOU PAY?

1. NO LONGER HAVE COST HAVE COST

$

2. NO LONGER HAVE COST HAVE COST

$

3. NO LONGER HAVE COST HAVE COST

$

CHANGE IN MEDICAL COSTS (Doctors, Dentists, Hospitals, Prescriptions, etc.) – You are only required to report changes in your medical expenses at recertification. However, you may voluntarily report changes in your medical expenses at any time for household members who are:

60 years old or older disabled spouse or children of a deceased veteran getting Supplemental Security Income (SSI) getting Social Security Disability payments getting veterans’ disability benefits getting government disability retirement benefits getting Railroad Retirement disability benefits getting disability-based medical assistance

If you report and verify an increase in your medical expenses, you may be eligible for more SNAP benefits.

NAME TYPE OF COST AMOUNT HOW OFTEN IS EACH PAYMENT DUE?

$

$

$

$

DO YOU EXPECT THE CHANGES YOU HAVE REPORTED TO CONTINUE NEXT MONTH? YES NO

If “NO”explain:

CHECK HERE IF YOU HAVE NO CHANGES TO REPORT ABOUT YOUR SNAP HOUSEHOLD NO CHANGES

BE SURE TO READ AND SIGN PAGE 6

PAGE 6 LDSS-3151 (Rev. 8/12)

CHANGE OF BENEFITS We will use your answers on this form to see if your household’s benefits will change. Before we change your benefits, we will send you a notice explaining what will happen. If you don’t agree with our decision, you have the right to a fair hearing to challenge our decision.

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) BENEFITS PENALTY WARNING

Any information you provide in connection with your application for SNAP benefits will be subject to verification by Federal, State and local officials. If any information is incorrect, you may be denied SNAP. You may be subject to criminal prosecution for knowingly providing incorrect information.

You will never be able to get SNAP again if you are:

Found guilty in a court of law for the second time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP: or

Found guilty in a court of law of selling or obtaining firearms, ammunition or explosives in exchange for SNAP; or

Found guilty in a court of law of trafficking in SNAP worth $500 or more. Trafficking includes the illegal use, transfer, acquisition, alteration or possession of SNAP, authorization cards or access devices; or

Found guilty in a court of law of committing a third Intentional Program Violation (IPV).

You will not be able to get SNAP for two years if you are found guilty in a court of law for the first time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP.

If you have committed your:

First IPV, you will not be able to get SNAP for one year.

Second IPV, you will not be able to get SNAP for two years.

A court could also bar you from receiving SNAP benefits for an additional 18 months.

If you make a false statement about who you are or where you live in order to get multiple SNAP, you will not be able to get SNAP for ten years (or permanently if this is the third IPV).

You may be found guilty of an Intentional Program Violation if you:

Make a false or misleading statement, or misrepresent, conceal or withhold facts; or

Commit any act that constitutes a violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of SNAP benefits, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system.

You could also be fined up to $250,000, sent to jail for up to 20 years, or both. CERTIFICATION

I understand the penalty for hiding or giving false information. I also understand I will owe the value of any extra SNAP benefits I receive because I don’t fully report changes in my household. I agree to prove any changes reported if necessary. The answers on this form are correct and complete to the best of my knowledge. I understand that my signature authorizes federal, state and local officials to contact other persons or organizations to verify the information I have provided. SIGNATURE

X

DATE

LDSS-3151-SP (Rev. 8/12) PÁGINA 1

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE CASO NÚMERO PROGRAMA DE ASISTENCIA NUTRICIONAL

SUPLEMENTARIA (SNAP) FORMULARIO DE INFORME DE CAMBIOS

(Favor de escribir en letra de molde legible)

SE LE EXIGE INFORMAR TODO CAMBIO EN LA SITUACIÓN DE SU HOGAR FECHA: SEGÚN LAS REGLAS A CONTINUACIÓN: LLENE ESTE FORMULARIO Y ENVÍELO POR CORREO A:

SR.(A): NOMBRE, DIRECCIÓN Y NÚMERO TELEFÓNICO DEL DISTRITO LOCAL:

DOMICILIO:

RESPONSABILIDAD DE INFORMAR CAMBIOS

Lea las preguntas y reglas con atención. Si usted no informa un cambio que está obligado a informar, de acuerdo con las reglas establecidas, es posible que tengamos que iniciar un reclamo por pago excesivo de Asistencia Nutricional Suplementaria (SNAP – por sus siglas en inglés) y cobrarle dicho monto.

Los cambios que ESTÁ OBLIGADO a informar se explican a continuación. Usted puede informar, voluntariamente, todo cambio en la composición del grupo familiar que recibe SNAP. Si el cambio a reportar tendría como resultado un aumento en la cantidad de beneficios que recibe, una vez usted presente comprobantes de dicho cambio, aumentaremos la cantidad de beneficios que recibe.

¿PRESENTA USTED UN REPORTE «CADA SEIS MESES» O SÓLO CADA VEZ QUE HAY CAMBIOS A REPORTAR «REPORTE DE CAMBIOS»? CONTESTE LAS SIGUIENTES PREGUNTAS PARA DETERMINAR SI DEBE INFORMAR CADA SEIS MESES O A MEDIDA QUE SE DAN LOS CAMBIOS.

1. ¿Recibe usted beneficios Transitorios de SNAP (TBA)?

SÍ – Vaya a la sección de beneficios transitorios «TBA» en la página 3 (Salte las preguntas 2 a 8)

NO – Vaya a la pregunta #2, a continuación

2. ¿Recibe beneficios del Proyecto de Mejora Nutricional del Estado de Nueva York (New York State Nutritional Improvement Project -NYSNIP-)?

SÍ – Vaya a «NYSNIP» en la página 3 (Salte las preguntas 3 a 8)

NO – Vaya a la pregunta #3, a continuación

3. ¿Se le ha aprobado para recibir SNAP por un periodo de tres meses a la vez o por menos tiempo?

SÍ –Vaya a «Reporte de cambios» en la página 2 (Salte las preguntas 4 a 8)

NO – Vaya a la pregunta #4, a continuación

4. ¿Algún miembro de familia tiene ingresos trabajados que se toman en cuenta al hacer el cálculo de la cantidad de beneficios SNAP que recibe?

SÍ –Vaya a «Reporte de seis meses» en la página 2 (Salte las preguntas 5 a 8)

NO – Vaya a la pregunta #5, a continuación

5. ¿Hay adultos (de 18 años o mayor) en el hogar que estén incapacitados o que tengan 60 años de edad o más?

SÍ –Vaya a «Reporte de cambios» en la página 2 (Salte las preguntas 6 a 8)

NO – Vaya a la pregunta #6, a continuación

6. ¿Recibe su hogar $0 ingresos (incluyendo $0 en Asistencia Temporal)?

SÍ –Vaya a «Reporte de cambios» en la página 2 (Salte las preguntas 7 y 8)

NO – Vaya a la pregunta #7, a continuación

7. ¿No tiene usted vivienda (domicilio fijo) o es trabajador agrícola migratorio o temporal?

SÍ – Vaya a «Reporte de cambios» en la página 2 (Salte la pregunta 8)

NO – Vaya a pregunta #8, a continuación

8. ¿Contestó «No» a las 7 preguntas anteriores?

Vaya a «Reporte de seis meses» al principio de la página 2

FORMULARIO DE INFORME DE CAMBIOS PÁGINA 2 LDSS-3151-SP (Rev. 8/12)

REGLAS DEL REPORTE DE LOS SEIS MESES

Como hogar beneficiario de SNAP, según las las reglas de «Informe de Cambios de Seis Meses», usted solamente tiene que informar cambios en la próxima revalidación, excepto en las tres situaciones siguientes:

1. Si el ingreso bruto mensual del hogar sobrepasa por un 130 % el índice nacional de pobreza, DEBE reportar esa cantidad mensual al distrito de servicios sociales, ya sea, por teléfono, por escrito o en persona, dentro de los 10 días de finalizado el mes calendario en el que el ingreso sobrepasa por un 130 %. El ingreso bruto es la cantidad de ingresos antes de descontar impuestos y otras deducciones, y no la cantidad que usted recibe cuando cobra su cheque. Al calcular la cantidad del subsidio SNAP que usted recibirá, usamos el monto del ingreso bruto. La persona a cargo de su caso le explicará qué significa el 130 % del índice nacional de pobreza para una familia con el número de miembros en el hogar como la suya. Todo otro tipo de ingreso que usted reciba, además de los ingresos trabajados, deben agregarse a su ingreso bruto ganado para determinar si usted sobrepasa el 130 % del índice nacional de pobreza. Ejemplos de otros tipos de ingresos que se toman en cuenta son: pagos de Sustento de Menores, Seguro de Desempleo, pagos de Asistencia Temporal (TA), pagos por Compensación Laboral, Seguro Social, Seguridad de Ingreso Suplementario (SSI) o beneficios privados por incapacidad.

Si usted no nos informa que sus ingresos brutos sobrepasan el 130 % del índice nacional de pobreza en un determinado mes calendario; todos los beneficios recibidos después de ese mes se podrían considerar como pagos excesivos. Esto aplica aun cuando su ingreso bruto sea menos del 130 % del índice nacional de pobreza en un mes futuro.

2. Cuando el período de certificación de su hogar dura más de 6 meses: en la fecha de la revisión de los seis meses de su período de certificación, recibirá un formulario de informe que DEBE devolver dentro de los diez días de recibirlo. Si en su hogar se han producido algunos de los cambios que se mencionan a continuación, usted DEBE informarlos en el formulario que se le envía a la fecha de revisión de los seis meses.

Lista de cambios que debe informar en la revisión de los seis meses:

Cambios en cualquier fuente de ingresos de cualquier miembro de su hogar

Cambios en el total de ingresos trabajados de su hogar cuando este total aumenta o disminuye por más de $100 al mes

Cambios en el total de ingresos no trabajados de su hogar provenientes de fondos públicos, tales como beneficios de Seguro Social o beneficios del Seguro de Desempleo (UIB), cuando este total aumenta o disminuye por más de $50 al mes

Cambios en el total de ingresos no trabajados de su hogar provenientes de fondos privados, tales como pagos de Sustento de Menores o pagos del seguro privado por incapacidad, cuando este total aumenta o disminuye por más de $100 al mes

Cambios en los pagos por orden judicial de Sustento para Menores para un(a) niño(a) que no sea miembro del hogar beneficiario de SNAP.

Cambio en a quiénes viven con usted

Si se muda, su nueva domicilio, o los nuevos montos de alquiler o hipoteca, gastos de calefacción y servicios públicos

Un automóvil nuevo o diferente, u otro vehículo

Aumento en la cantidad de dinero en efectivo, acciones, bonos, dinero en el banco o instituciones de ahorro cuando la cantidad total en efectivo y en ahorros de todos los miembros del hogar es más de $2000 (o más de $3250 si algún miembro del hogar está incapacitado(a) o tiene 60 años de edad o más)

Todo cambio, en la circunstancias de su hogar, que pudiese resultar en una sanción, tal como se explica en la página 6. 3. Si un integrante del grupo familiar que recibe SNAP es un Adulto Habilitado para Trabajar sin Dependientes (Able-Bodied Adult

Without Dependents - ABAWD), usted DEBE informarnos si esa persona trabajó menos de 80 horas al mes. Debe reportarlo dentro de los diez días de finalizado el mes en que se dio ese cambio.

REGLAS SOBRE INFORME DE CAMBIOS

Según las reglas de «Informe de Cambios», un hogar que reciba SNAP DEBE reportar los siguientes cambios dentro de los 10 días de ocurrido:

Cambios en la fuente de ingresos de miembros del hogar.

Cambios en el total de ingresos trabajados del hogar cuando este total aumenta o disminuye por más de $100 al mes

Cambios en el total de ingresos no trabajados del hogar provenientes de fondos públicos, tales como beneficios de Seguro Social o beneficios del Seguro de Desempleo (UIB), cuando este total aumenta o disminuye por más de $50 al mes.

Cambios en el total de ingresos no trabajados del hogar provenientes de fondos privados, tales como pagos de Sustento de Menores o pagos del seguro privado por incapacidad, cuando este total aumenta o disminuye por más de $100 al mes.

Cambios en los pagos por orden judicial de Sustento de Menores de un(a) niño(a) que no sea miembro del hogar beneficiario de SNAP.

Cambios en cuanto quiénes viven con usted.

Si se muda, su nuevo domicilio, o los nuevos montos de alquiler, hipoteca; gastos de calefacción y servicios públicos.

Un automóvil nuevo o diferente, u otro vehículo.

Aumento en la cantidad de dinero en efectivo, acciones, bonos, dinero en el banco o instituciones de ahorro, cuando la cantidad total en efectivo y en ahorros de todos los miembros del hogar es más de $2000, si en el hogar no hay miembros de edad avanzada, o con una incapacidad permanente; o más de $3250 si en el hogar hay miembros de edad avanzada o con una incapacidad permanente.

Si un integrante del hogar beneficiario de SNAP es un Adulto Habilitado para Trabajar sin Dependientes (Able Bodied Adults Without Dependents- ABAWD), usted DEBE informarnos si esa persona trabajó menos de 80 horas al mes; debe informar este cambio dentro de los diez días de finalizado el mes en en el que se dio el cambio.

Todo cambio, en las circunstancias de su hogar, que pudiese resultar en una sanción, tal como se explica en la página 6.

FORMULARIO DE INFORME DE CAMBIOS PÁGINA 3 LDSS-3151-SP (Rev. 8/12)

INFORME DE CAMBIOS – Hogares que reciben beneficios transitorios (TBA): Puede continuar recibiendo los beneficios transitorios de SNAP por un período de hasta cinco meses

después de que se cierra su caso de Asistencia Temporal. No se le requiere reportar cambios durante el período de transición. Si ciertos cambios tuviesen como

resultado un aumento en sus beneficios; para recibir el aumento, comuníquese con la persona a cargo de su caso y solicite una solicitud temprana de revalidación; esto puede hacerlo en cualquier momento durante el período de transición. No se le puede aprobar el aumento hasta que no presente una solicitud firmada de revalidación y pase por todo el proceso de revalidación.

Se le exige presentar una revalidación próximo a la fecha de vencimiento de su período de transición para determinar si puede continuar recibiendo el subsidio SNAP una vez finalizado el período de transición. Le enviaremos un aviso recordándole este requisito de revalidación. Si usted no presenta una revalidación, no le enviaremos ningún otro aviso y nos veremos obligados a cerrar su caso de SNAP.

REPORTE DE CAMBIOS - Participantes del Proyecto de Mejora Nutricional del Estado de Nueva York - NYSNIP:

24 meses después de empezar a participar en el proyecto NYSNIP, recibirá una carta que debe rellenar y devolver.

Aparte de la carta que usted recibe a los 24 meses, no se le requiere reportar ningún cambio durante el período de revalidación. Puede, voluntariamente, reportar aumentos en gastos médicos, alquiler o servicios públicos o disminución de ingresos. Si usted reporta y comprueba esos cambios, es posible que reciba un aumento en la cantidad del subsidio SNAP que recibe. No es obligatorio, pero le sugerimos que si se muda nos informe de su nuevo domicilio, de manera que pueda seguir recibiendo los avisos que le enviamos.

Gastos médicos: no tiene que reportar cambios en sus gastos médicos durante el período de certificación. Sin embargo, puede, voluntariamente, informar cambios en los gastos médicos que incurran los miembros del hogar que:

- tengan 60 años de edad o más - reciban subvención por incapacidad para veteranos - sean cónyuges incapacitados o hijos incapacitados de un veterano fallecido

- pensión gubernamental de jubilación por incapacidad

- reciban Seguridad de Ingreso Suplementario (SSI) - pensión de jubilación ferroviaria por incapacidad - reciban pagos del Seguro Social por Incapacidad - asistencia médica por incapacidad

Si usted reporta y demuestra el aumento en sus gastos médicos, es posible que reciba un aumento en el subsidio SNAP. Los cambios en los gastos médicos deben reportarse en su próxima cita de revalidación.

Asistencia Temporal (TA) - Reglas sobre informe de cambios: las reglas anteriores aplican sólo al programa de SNAP. Si usted también recibe Asistencia Temporal (TA), igualmente se le requiere reportar cambios relacionados al programa de TA dentro de los 10 días de haberse producido el cambio, en las comunicaciones periódicas de reporte, en los cuestionarios para determinar si satisface los requisitos para recibir TA y durante la revalidación.

¿Cuándo debe usar este formulario?

Puede usar este formulario para informar cambios obligatorios o voluntarios. También, puede utilizar este formulario para informar cambios en el costo de cuidado de niños o adultos incapacitados, o cambios en los costos de vivienda, aunque no se haya mudado. De haber un aumento en estos gastos, usted podría recibir un aumento en el subsidio SNAP.

Si tiene comprobantes de los cambios que está reportando, favor de adjuntarlos a este formulario para asegurarnos que recibe la cantidad correcta de SNAP. Debemos verificar los cambios que reporta antes de aumentarle el monto del subsidio SNAP.

Este formulario debe enviarlo por correo o traerlo a la agencia mencionada arriba. Si por algún motivo no puede enviarlo por correo o entregarlo en persona, reporte los cambios por teléfono al número que aparece en la página 1.

Si ya no desea recibir el subsidio SNAP, firme quí y le retiraremos del programa. De esta manera dichos beneficios cesarán. Ya no recibirá el subsidio SNAP. Tiene derecho a oponerse a este retiro y solicitar una audiencia imparcial dentro de los próximos 90 días si considera que se le proporcionó información incorrecta o incompleta sobre los requisitos del programa de SNAP. Puede volver a solicitar el subsidio SNAP cuando usted lo desee aunque se haya retirado antes.

X

SI USTED NO REPORTA LOS CAMBIOS QUE ESTÁ OBLIGADO A REPORTAR, NOS ADEUDARÁ EL VALOR DEL SUBSIDIO ADICIONAL DE SNAP QUE RECIBIÓ COMO RESULTADO DE NO REPORTAR DICHOS CAMBIOS. SI USTED, A SABIENDAS, RETIENE INFORMACIÓN QUE ESTÁ OBLIGADO A REPORTAR, SE LE PUEDE ELIMINAR DEL PROGRAMA SNAP Y SOMETER A UN JUICIO EN LO PENAL (CONSULTE EL TEMA ADJUNTO TITULADO «ADVERTENCIA SOBRE LAS SANCIONES RELACIONADAS CON EL PROGRAMA DE ASISTENCIA NUTRICIONAL SUPLEMENTARIA - SNAP» EN LA PÁGINA 6).

FORMULARIO DE INFORME DE CAMBIOS PÁGINA 4 LDSS-3151-SP (Rev. 8/12)

Use el formulario a continuación para informar cambios CAMBIO EN INGRESOS O FUENTE DE INGRESOS – Si se reporte cada seis meses, las reglas pertinentes a dichos cambios las encuentra en la página 2. Y si reporta cambios según se dan, o reporte por cambios, las reglas las encuentra también en la página 2.

NOMBRE DE LA PERSONA QUE RECIBE EL INGRESO

FUENTE DE INGRESO NUEVA CANTIDAD ¿CON QUÉ FRECUENCIA LO RECIBE?

1. $

2. $

3. $

CAMBIOS EN EL HOGAR: Incluya todos los nuevos miembros del hogar, incluyendo recién nacidos. También incluya a miembros que se hayan incorporado o retirado del hogar o que hayan fallecido.

NOMBRE EDAD PARENTESCO CAMBIO (MARQUE UNO) FECHA

CANTIDAD DEL INGRESO

FUENTE

1.

LLEGÓ AL HOGAR SE FUE DEL HOGAR

$

2.

LLEGÓ AL HOGAR SE FUE DEL HOGAR

$

3.

LLEGÓ AL HOGAR SE FUE DEL HOGAR

$

4.

LLEGÓ AL HOGAR SE FUE DEL HOGAR

$

CAMBIO DE DOMICILIO NUEVA DIRECCIÓN DE CORREO CIUDAD ESTADO CÓDIGO POSTAL

SI SU DOMICILIO NO INCLUYE EL NOMBRE DE LA CALLE, PROPORCIONE INSTRUCCIONES PARA LLEGAR A SU CASA (si está desamparado(a), deje este espacio en blanco)

No. DE TELÉFONO DONDE SE LE PUEDE LLAMAR Código de área

( ) CAMBIOS EN LOS COSTOS DE VIVIENDA: Si se ha mudado, se le exige indicar abajo sus nuevos gastos. Aunque no se haya mudado, puede usar esta sección para indicar cambios en su alquiler, pagos de hipoteca u otros gastos.

¿Es usted pensionista o renta una habitación?

SÍ NO Si contesta Sí, las comidas ESTÁN INCLUIDAS NO ESTÁN INCLUIDAS

ALQUILER/RENTA SÍ NO

¿SÍ? INDIQUE CANTIDAD

MENSUAL CAMBIO (MARQUE UNO)

¿Paga usted por el alquiler/renta? $ Igual Más Menos ¿Paga los siguientes gastos por separado del alquiler/renta? SÍ NO

Calefacción y/o aire acondicionado $

Servicios públicos (electricidad, gas para cocinar, etc.) $

Teléfono $

PAGO DE HIPOTECA SÍ NO ¿SÍ? INDIQUE CANTIDAD MENSUAL CAMBIO (MARQUE UNO)

¿Paga usted una cuota de hipoteca? $ Igual Más

Menos ¿Paga los siguientes gastos por separado de la hipoteca?

Sí NO ¿SÍ? INDIQUE CANTIDAD MENSUAL CAMBIO (MARQUE UNO)

Impuesto sobre la propiedad $ Igual Más Menos

Seguro de vivienda $ Igual Más Menos

Calefacción y/o aire acondicionado

Servicios públicos (electricidad, gas para cocinar, etc.)

Teléfono

¿Vive usted en una vivienda de la «Sección 8» u otra vivienda subsidiada? SÍ NO ¿Vive usted en una vivienda pública? SÍ NO

FORMULARIO DE INFORME DE CAMBIOS PÁGINA 5 LDSS-3151-SP (Rev. 8/12)

CAMBIOS EN LA CANTIDAD DE AUTOMÓVILES O VEHÍCULOS: ¿Algún miembro de su hogar compró, vendió o intercambió un automóvil, camión, barco, casa rodante, motocicleta u otro vehículo desde la última vez que nos informó acerca de sus vehículos?

MARCA MODELO AÑO SI LO VENDIÓ, CANTIDAD RECIBIDA

1. $

2. $

3. $

CAMBIOS EN LOS AHORROS: Incluya el total de dinero que los miembros de su hogar tienen actualmente. Incluya dinero en efectivo, cuentas de ahorro, cuentas corrientes, acciones, bonos u otras inversiones. Se le exige informarnos si los ahorros de su hogar han aumentado a más de $2,000 (o más de $3250 si un miembro del hogar tiene 60 años de edad o más, o es una persona incapacitada).

$

CAMBIOS EN EL CUIDADO DE NIÑOS, GASTOS POR EL CUIDADO DE DEPENDIENTES O EN LA CANTIDAD PAGADA DE SUSTENTO DE MENORES: ¿Han habido cambios en los gastos de cuidado de niños o el cuidado de dependientes? De ser así, podría recibir un aumento en el subsidio SNAP.

CAMBIO (MARQUE UNO)

¿PARA QUIÉN? ¿A QUIÉN LE PAGA UD.?

NUEVA CANTIDAD

FRECUENCIA DEL PAGO

1. YA NO TIENE EL GASTO TIENE EL GASTO

$

2. YA NO TIENE EL GASTO TIENE EL GASTO

$

3. YA NO TIENE EL GASTO TIENE EL GASTO

$

CAMBIOS EN GASTOS MÉDICOS (médicos, dentistas, hospitales, recetas médicas, etc.) – Sólo se le requiere informar los cambios en gastos médicos al momento de la revalidación. Sin embargo, cuando lo desee, puede voluntariamente reportar los gastos médicos de miembros del hogar que:

tengan 60 años de edad o más

sean cónyuges incapacitados(as) o hijos/hijas de un veterano fallecido

reciban Seguridad de Ingreso Suplementario (SSI)

reciban beneficios del Seguro Social por Incapacidad

reciban beneficios por incapacidad para veteranos

reciban beneficios gubernamentales de jubilación por incapacidad

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reciban asistencia médica por incapacidad

Si usted reporta y demuestra el aumento en gastos médicos, podría recibir un aumento en el subsidio SNAP.

NOMBRE TIPO DE GASTO CANTIDAD ¿CON QUÉ FRECUENCIA HACE ESTE PAGO?

$

$

$

$

¿CREE QUE LOS CAMBIOS QUE HA REPORTADO SE REPETIRÁN EL PRÓXIMO MES? SÍ NO

Si contesta «NO», explique la razón:

MARQUE ESTA CASILLA SI NO TIENE CAMBIOS QUE REPORTAR SOBRE EL HOGAR QUE RECIBE SNAP

NO HAY CAMBIOS

ASEGÚRESE DE LEER Y FIRMAR LA PÁGINA 6

FORMULARIO DE INFORME DE CAMBIOS PÁGINA 6 LDSS-3151-SP (Rev. 8/12)

CAMBIO DE BENEFICIOS La información que usted proporcione en este formulario se usará para determinar si se modificarán sus beneficios. Si se modifican, se le enviará un aviso explicándole lo que sucederá antes de realizar el cambio. Si no está de acuerdo con nuestra determinación, tiene el derecho a solicitar una audiencia imparcial para interponerse a nuestra decisión.

ADVERTENCIA SOBRE SANCIONES RELACIONADAS CON EL PROGRAMA DE ASISTENCIA NUTRICIONAL SUPLEMENTARIA - SNAP

La información que usted brinde en relación con su solicitud de SNAP estará sujeta a verificación por autoridades federales, estatales y locales. Se le podrá negar el subsidio SNAP si nos percatamos que proporcionó información inexacta. Se le podrá someter a un proceso en lo penal por suministrar, a sabiendas, información inexacta.

Usted nunca más podrá volver a recibir el subsidio SNAP si:

Un tribunal de justicia lo/la declara culpable por segunda vez de comprar o vender sustancias controladas (drogas ilegales o drogas para las cuales se requiere una receta médica) a cambio de SNAP: o

Un tribunal de justicia lo/la declara culpable de vender u obtener armas de fuego, municiones o explosivos a cambio de SNAP; o

Un tribunal de justicia lo/la declara culpable de traficar cupones por un valor de $500 ó más. El tráfico incluye el uso, la transferencia, la adquisición, alteración o la posesión ilegal de fondos SNAP, tarjetas de autorización o elementos de acceso; o

Un tribunal de justicia lo/la declara culpable de cometer una tercera Violación Intencional del Programa

Usted no podrá recibir SNAP durante dos años si un tribunal de justicia lo/la declara culpable por primera vez de comprar o vender sustancias controladas (drogas ilegales o drogas para las cuales se requiere una receta médica) a cambio de SNAP. Por la:

Primera Violación Intencional del Programa (IPV), usted no podrá recibir SNAP por un año.

Segunda Violación Intencional del Programa (IPV), usted no podrá recibir SNAP por dos años.

Además, una orden judicial podrá prohibirle recibir SNAP por un período adicional de 18 meses.

Si hace una declaración falsa sobre su identidad o sobre su domicilio con el propósito de recibir múltiples subsidios de SNAP, se le prohibirá recibir SNAP por diez años (o de forma permanente si ésta fuese la tercera violación que usted comete).

Se le puede declarar culpable de una violación intencional del programa (IPV) si usted:

Hace una declaración falsa, engañosa o una representación falsa, oculta o retiene hechos; o

Comete un acto que constituya violación de una ley federal o estatal con el objeto de usar, presentar, transferir, adquirir, recibir, poseer o traficar fondos de SNAP, tarjetas de autorización o documentos reutilizables del sistema de Transferencia Electrónica de Beneficios (EBT).

Además, se puede imponer una multa de hasta $250,000 o pena de prisión de hasta 20 años, o ambas. CERTIFICACIÓN

Comprendo la naturaleza del castigo que se impone por ocultar o suministrar información falsa. También, comprendo que adeudaré el valor de todo monto adicional que reciba de SNAP como resultado de no informar todos los cambios que ocurran en mi grupo familiar. Acepto comprobar los cambios, si fuese necesario. Las respuestas en este formulario son exactas y completas según mi leal saber y entender. Entiendo que mi firma en este documento autoriza a las autoridades federales, estatales y locales a comunicarse con personas u organizaciones con el fin de verificar la información que he proporcionado.

FIRMA X

FECHA

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