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

Appendix C – Page 2 Rev. 3/2022

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 For copies of LDSS-4004A, please use the following links: English Version - http://otda.state.nyenet/ldss_eforms/eforms/4004A.pdf Spanish Version - http://otda.state.nyenet/ldss_eforms/eforms/4004A-SP.pdf When to use an LDSS-4004A

In accordance with 18 NYCRR 385.12, a recipient must be issued an adequate and timely notice of intent to discontinue or reduce assistance which informs the recipient that they have refused or failed to comply willfully and without good cause with employment requirements. The automated Client Notice System (CNS) was designed to satisfy all requirements for notifying clients of the action taken on their cases. CNS codes are available to cover all decisions, and when used correctly, a timely and accurate notice is generated. Districts are encouraged to use CNS to generate the notice of intent but may use the manual notice of intent (LDSS-4004A), as determined appropriate by the district. Whenever manual notice(s) are used, staff should ensure the notice is complete and accurate and that a copy is maintained in the case record. When sending a manual notice of intent for failure to comply with TA employment requirements, district’s outside of NYC must complete the LDSS-4004A or an approved local equivalent and provide it to the client. This notice is to be used in cases of TA work activity noncompliance. It is for use in cases of individual sanction or case closure. Instructions for Completion

Notice Date - The date the worker completes and mails the notice. The date must be at least ten days before the effective date of the action. Effective Date - The date the action or change will occur. Fair hearing regulations require that notice be given as to when an action will take effect. The effective date is used to determine if aid continuing can be given until the fair hearing decision is issued. In order for an appellant to have the right to aid continuing, the fair hearing must be requested by the effective date. The top portion consists of identifying information which is self- explanatory.