Snap Form W 113K – Fill Out and Use This PDF

PB #07-36-OPE

•The first paragraph under the title has been changed to:

“In order to make a determination of or maintain your current eligibility for public assistance (PA) and/or food stamps (FS), you must provide the documents and/or information indicated below, together with this form, by the due date. If you cannot get the required documents/information by the due date, contact your Worker and ask for an extension. If you cannot get the required documents/information at all, contact your Worker immediately, as s/he may assist you in obtaining the required documents/information. The W-119D, which lists the common documents that may be used to verify the eligibility factors, is attached.”

•A “due date” line and checkbox indicating “Must see Worker upon return” have been added.

•A “Forms Reminder” section has been added, a series of Agency forms with checkboxes, which will be completed by the Worker to remind the applicant/participant of documentation needed to complete the eligibility process.

•A “PA Appointment Reminder” section has been added, which consists of appointments that the applicant/participant may be required to participate in to complete the eligibility/recertification process.

•At the top of page 2, checkboxes have been added to identify whether any household members are required to come in to the Office/Center to be finger-imaged, assessed for employment or to sign the public assistance application.

•The Eligibility Factors Chart has been moved to page 2 and the two right-hand columns have been removed.

•The text “Outstanding documentation – see the W-119D for a list of documents that can be used to verify the outstanding eligibility factors” has been added above the chart on page 2.

•The text below the chart was changed to read:

“If this notice does not indicate that you (casehead) must see the Worker upon return, you may submit any required documents/information by mail. However, it remains your responsibility to ensure that the required information reaches the Agency by the prescribed deadline.”

FIA Policy, Procedures and Training

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Office of Procedures

PB #07-36-OPE

•The bold text was changed to read:

“Failure to submit verification/documentation or contact us on or before the due date may make you ineligible for public assistance and/or food stamps, or may cause a reduction in your public assistance and/or NPA Food Stamp benefits for a specific period of time.”

The following revisions apply to the new W-119D:

•The form has been changed to reflect the flow of categories and subcategories on the LDSS-2642 and has increased from two to three pages.

•On page 1, the “Obtain One” column has been replaced with two columns; the applicant/participant needs one item from the first column or two items from the second column to prove the checked eligibility factor(s). On pages 2 and 3 there is only one column and the applicant/participant will be required to provide one item from the column for each checked factor to prove eligibility.

•On page 1, the statement “(not required for Food Stamps)” was added to the “Marital Status,” “Absence/Death of Parent(s)” and “Absent Parent Information” sections.

•On page 1, for section “Relationship,” the proof “Marriage Certificate was removed and the proofs “Medical Records,” “Applicant’s statement,” “Newspaper Notice,” “Statement from Clergy,” and “Statement form another person” were added.

•On page 2, the subheading, “Private Pension/Annuity” has been added to the “Unearned Income” section.

•On page 2, the subheading “Cash on hand” has been removed from the “Resources” section.

•On page 2, the proof, “Current benefit check” for the subheading “Unemployment Insurance Benefits (UIB) in the section “Unearned Income” has been removed because applicants/participants no longer receive a check (payment is through a direct payment card).

•On page 3, the statement “You must prove rent and other household expenses” has been removed from the “Shelter Expenses” section and replaced with the statement “You must prove how much it costs you to live where you do (you may need to provide separate documentation for each item of shelter expense).

•On page 3, the statement “For FS, for aged/disabled individuals only” was added to the “Medical Expenses” section.

•On page 3, the bulleted item “Medicare prescription drug card” was added as an additional proof for medical expenses.

FIA Policy, Procedures and Training

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Office of Procedures

PB #07-36-OPE

•On page 3, the statements “If you or anyone living with you is sick or pregnant, you must provide proof” and “(For MA only, resource information is not requested from pregnant women, children and persons eligible for Family Health Plus)” have been added to the “Disabled/Incapacitated/Pregnant” section.

•On page 3, the item “Medical” was removed from the “Unpaid Bills” section.

•On page 3, the statement “(for Safety Net Assistance)” was added under the section head “Past Management” because the program requirements only apply to Safety Net Assistance, not Family Assistance.

•On page 3, four new eligibility factors, “Referral” (with subheading “Employment Service),” “Past Management” (with subheadings “Earned Income” and “Other”), “Potential Benefits” and “Other,” have been added.

Center Directors and NPA FS Office Site Managers must ensure that all previous versions of this form and the multilingual equivalents are removed from circulation and recycled.

Effective Immediately

References:

00-INF-6

05-INF-16

Temporary Assistance Source Book (Chapter 5, page 45) Food Stamp Source Book (Section 17, page 375)

Related Items:

PB #04-10-OPE

PB #04-179-OPE

FIA Policy, Procedures and Training

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Office of Procedures