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

Appendix C – Page 6 Rev. 3/2022

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

Districts are required to provide a timely and adequate notice of intent to reduce or discontinue TA and/or SNAP benefits to inform the household that an individual in the household is sanctioned from TA and/or SNAP benefits because they have refused or failed to comply with employment requirements. The automated Client Notice System 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. 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. Changes made in Chapter 562 of the Laws of 2015 eliminated durational TA employment sanction periods for individuals who reside in a city having a population of one million or more people. The TA employment sanction language generated through CNS was modified consistent with the requirements of SSL §342-a. The LDSS-4004A NYC was created for use by the NYC Human Resource Administration (HRA) when sending a manual notice of intent to inform the household of a TA employment sanction. When to use an LDSS-4004A-NYC

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 without good cause with employment requirements. Districts are encouraged to use CNS to generate the notice of intent but may use the manual notice of intent (LDSS-4004A-NYC), 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 to a TA recipient in NYC the LDSS-4004B-NYC or an approved local equivalent must be provided to the client. This notice is to be used in cases of TA work activity non-compliance. It is for use in cases of individual sanction or case closure.