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

Appendix C – Page 8 Rev. 3/2022

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

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

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

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

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

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

In accordance with 18 NYCRR 385.2, if an applicant or recipient of temporary assistance claims that 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. 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 or an approved local equivalent shall be used to notify an individual of the district’s determination that they are 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 on that day. The top portion consists of identifying information which is self- explanatory. The first checkbox (Part 1 - Medical) applies to an individual who was found to have a personal medical condition which would exempt them from work activities. It explains to the individual the effective date of the determination, that they may be required to supply medical evidence at some future time to verify continued exemption status based on disability, and that they may be required to participate in treatment to become self-sufficient. It also notifies the individual that