Page 19

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

Appendix C – Page 19 Rev. 3/2022

LDSS-5087 NYC RE-ENGAGEMENT AND CONCILIATION NOTICE For copies of the LDSS-5087 NYC use the following links:

• English Version LDSS-5087 NYC https://otda.state.nyenet/ldss_eforms/eforms/5087- NYC.pdf

• Spanish Version LDSS-5087 NYC https://otda.state.nyenet/ldss_eforms/eforms/5087- NYC-SP.pdf

The LDSS-5087 NYC is for use by staff in New York City for TA and/or SNAP noncompliance in those instances where a manual conciliation notice is needed. Instructions for completing the LDSS-5087 NYC

The re-engagement/conciliation notice must:

• identify the specific act or acts of noncompliance (failure or refusal to comply or participate) that has/have taken place;

• inform the individual of the right to avoid the pro-rata reduction in TA benefits through reengagement (demonstrating compliance with assigned work requirements, by documenting an exemption consistent with 18 NYCRR 385.2 or by otherwise demonstrating that the noncompliance was not willful or with good cause);

• indicate that HRA has reviewed the case record and based on the information available determined that the individual is not exempt from work requirements and that the necessary supportive services and accommodations for a disability were available at the time of the noncompliance;

• explain what would constitute good cause and provide examples of acceptable forms of documentation that may be provided to HRA to warrant an exemption or excused absence, (e.g., medical note, letter from the court, etc.); and,

• indicate that the individual has ten calendar days to appear at the conciliation appointment to explain why he/she did not participate in the assigned work requirement.

For individuals who participate in the conciliation appointment HRA must evaluate good cause and whether the noncompliance was willful. The individual is responsible for notifying HRA of the reasons for refusing or failing to comply with a work requirement and for providing documentation to support any claim of good cause, or exemption from work requirements. Since the determination of good cause may be based upon the credible explanation provided by