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NYS Office of Temporary and Disability Assistance- TA and SNAP Employment Policy Manual
Appendix C – Page 1 Rev. 3/2022
Appendix C - Client Notices and Instructions
Table of Contents Appendix C - Client Notices and Instructions ............................................................................. 1 LDSS-4004A NOTICE OF INTENT TO CHANGE BENEFITS – PART A PUBLIC ASSISTANCE GRANT AND/OR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) BENEFITS FOR NONCOMPLIANCE WITH WORK RELATED (TIMELY AND ADEQUATE) AND NOTICE OF EFFECT ON MEDICAID BENEFITS .................................... 2 LDSS-4004B NOTICE OF INTENT TO CHANGE BENEFITS – PART B PUBLIC ASSISTANCE GRANT AND/OR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) BENEFITS FOR NONCOMPLIANCE WITH WORK RELATED (TIMELY AND ADEQUATE) AND NOTICE OF EFFECT ON MEDICAID BENEFITS .................................... 4 LDSS-4004A-NYC NOTICE OF INTENT TO CHANGE BENEFITS – PART A, PUBLIC ASSISTANCE GRANT AND/OR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) BENEFITS FOR NONCOMPLIANCE WITH WORK RELATED (TIMELY AND ADEQUATE) AND NOTICE OF EFFECT ON MEDICAID BENEFITS .................................... 6 LDSS-4005 NOTIFICATION OF TEMPORARY ASSISTANCE WORK REQUIREMENTS DETERMINATION (EXEMPT) ................................................................................................ 8 LDSS-4005(a) NOTIFICATION OF TEMPORARY ASSISTANCE WORK REQUIREMENTS DETERMINATION (NON-EXEMPT) ......................................................................................10 LDSS-5193 IMPORTANT INFORMATION ABOUT SNAP WORK RULES (GENERAL, MANDATORY E&T, AND ABAWD) .......................................................................................12 LDSS-5193A IMPORTANT INFORMATION ABOUT SNAP WORK RULES (GENERAL AND MANDATORY E&T) ..............................................................................................................13 LDSS-5127- Able-Bodied Adults Without Dependents (ABAWD) Work Activity Letter ...........14 LDSS-4230 CONCILIATION NOTIFICATION ........................................................................15 LDSS-4230A SNAP CONCILIATION NOTIFICATION ...........................................................18 LDSS-5087 NYC RE-ENGAGEMENT AND CONCILIATION NOTICE ..................................19