Page 10

NYS Office of Temporary and Disability Assistance- TA and SNAP Employment Policy Manual

Appendix C – Page 10 Rev. 3/2022

LDSS-4005(a) NOTIFICATION OF TEMPORARY ASSISTANCE WORK REQUIREMENTS DETERMINATION (NON-EXEMPT)

For copies of LDSS-4005(a), please use the following links:

 English Version LDSS-4005(a) - http://otda.state.nyenet/ldss_eforms/eforms/4005A.pdf

 Spanish Version LDSS-4005(a)SP - http://otda.state.nyenet/ldss_eforms/eforms/4005A- SP.pdf

 English Version NYC LDSS-4005(a) - http://otda.state.nyenet/ldss_eforms/eforms/4005A- NYC.pdf

 Spanish Version NYC LDSS-4005(a)SP - http://otda.state.nyenet/ldss_eforms/eforms/4005A-NYC-SP.pdf When to use an LDSS-4005(a)

In accordance with 18 NYCRR 385.2, if an applicant or recipient of public assistance claims they should be exempt from work activities, or the district conducts the disability review procedure because an individual claims a personal medical limitation or demonstrates an inability to function in a work setting and a health barrier is suspected, the social services official should determine the individual’s exempt/non-exempt status. Additionally, the LDSS-4005(a) is issued whenever an individual’s status changes from exempt to non-exempt. Once this determination is made the social services official shall notify the applicant or recipient in writing of the determination and the right to request a fair hearing. The LDSS-4005(a) or an approved local equivalent shall be used to notify an individual of the district’s determination that they are non-exempt from work requirements. Instructions for Completion

The notice date is the effective date of the determination for purposes of establishing the period within which an individual has to request a fair hearing (10 or 60 days depending on whether the determination is medical or non-medical in nature). Once the notice date is established, the notice should be mailed or otherwise delivered to the individual that day. The top portion consists of identifying information that is self-explanatory.

The first checkbox (Part 1 - Medical Nonexempt) applies to individuals whose personal health status has been evaluated and who have been determined to be non-exempt from participation in work activities. It explains to the individual the effective date of the determination, and that they have 10 days from the notice date to request a fair hearing. Please note: the “effective date” of the determination and the “notice date” should be the same date.