Ldss 4013A Form – Fill Out and Use This PDF

LDSS-4013A NYC (Rev. 5/16)	ACTION TAKEN ON YOUR APPLICATION: PART A				PA, MA, SNAP App
PUBLIC ASSISTANCE, SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
	AND MEDICAL ASSISTANCE COVERAGE (NYC)
NOTICE		NAME AND ADDRESS OF AGENCY/CENTER OR DISTRICT OFFICE
DATE:
CASE NUMBER	CIN NUMBER
CASE NAME (And C/O Name if Present) AND ADDRESS
		GENERAL TELEPHONE NO. FOR		_________________________
		QUESTIONS OR HELP
		OR	Agency Conference	_________________________
			Fair Hearing information	_________________________
			and assistance
			Record Access	_________________________
			Legal Assistance information	_________________________

The action(s) taken on your application dated ____________________________ is explained below and on Part B, next to the checked box(es)  :

SEE PART B FOR SNAP BENEFITS AND FAIR HEARING INFORMATION.

PUBLIC ASSISTANCE

ACCEPTED for the period from __________________ to ____________________ for [name(s)] ________________________

_______________________________________________________________________ . You will get $______________, which will cover the

period from _________________ to _____________________. After this you will get $ _________________.

The above grant is based on a reduced budget because:

__________________ failed without good cause to cooperate with the Office of Child Support Enforcement (OCSE) on

__________________ by ___________________________________________________________ [18NYCRR 352.3(d)]:

To lift this sanction, call (_____)_____________. Read the detailed instructions on the back of this notice.

__________________ failed to comply with the following drug/alcohol treatment requirement(s) [18NYCRR 351.2(i)]:

screening	assessment	rehabilitation
or, has not provided consent or revoked consent to disclose treatment information to the agency.

A RECOUPMENT at the rate of ______ percent (%) is being taken against your Public Assistance. The reason for this recoupment is:

_____________________________________________________________________________________. If you believe the recoupment

at this rate will cause your family an undue hardship, you should contact your worker to explain your reason. An undue hardship means that a person does not have enough income to eat, to pay for shelter or utilities, to get necessary clothing, to buy general items of need, or to pay for medical needs not covered by Medical Assistance. Your worker will let you know what kind of proof you will need to show that the recoupment at this rate will cause an undue hardship. If we decide that the recoupment will cause an undue hardship, the recoupment rate will be changed to a rate between 5 and 10%. The recoupment rate must be at least 5%. This decision is based on 18 NYCRR 352.31(d).

DENIED for the following individuals:

If ALL is in listed in the first Name(s) field, every member of your household was DENIED for the same stated Reason(s).

Name(s): _________________________	Reason(s)_______________________________________________________________
Name(s): _________________________	Reason(s)_______________________________________________________________
Name(s): _________________________	Reason(s)_______________________________________________________________
Name(s): _________________________	Reason(s)_______________________________________________________________
The above decision(s) is based on 18 NYCRR	_________________________________________________________________.
MEDICAL ASSISTANCE

ACCEPTED for Medical Assistance effective __________________ for [name(s)] ______________________________________________

___________________________________________________________________________________________________________________

ACCEPTED for Medical Assistance with a SPENDDOWN, effective _____________________ for [name(s)] ______________________________

Your total monthly income is $ ______________________. Your total monthly deductions are $ _________________. The difference between

these figures is your monthly net income for Medical Assistance. This is $ _____________. The allowable income standard for a family

household your size is $ ____________. The difference between your net income and this standard ($__________________) is your monthly

excess income (18 NYCRR 360-4.8). The enclosed letter explains eligibility under the Excess Income Program and Optional Pay-In Program.

DENIED Medical Assistance effective _________________ for [name(s)]____________________________________________ because

_____________________________________________________________________________________________________________

In the event that you are hospitalized, you may be eligible for Medical Assistance and should contact this Department.

PENDED

We do not have enough information to decide your eligibility under the Medical Assistance program. Please contact us no later than

___________________________ at__________________________ so we can tell you the information we need.

Your application for Medical Assistance is being reviewed. We will send you our decision within thirty days.

Not applying for Medical Assistance. You did not indicate on the application that you wanted to apply for Medical Assistance.

OTHER ______________________________________________________________________________________________________

This above decision(s) is based on __________________________________________________________________.

Enclosure	BE SURE TO READ THE BACK OF PART B FOR YOUR RIGHTS ON HOW TO APPEAL THIS DECISION.
	DISTRIBUTION: White -CLIENT/FAIR HEARING COPY	Yellow – CLIENT COPY	Pink – AGENCY COPY