Snap Periodic Report Nyc Form – Fill Out and Use This PDF

LDSS-4310 (Rev. 1/13)

SECTION 1: Please list ALL income for EACH household member. If you are only receiving SNAP benefits, you only have to list earnings here for each household member who works.

(Examples of income include earnings from a job, Unemployment Insurance, Social Security Benefits, Supplemental Security Income [SSI])

Send in proof of all income that any household member got during the entire month of _______________________.

Since you participate in the Child Assistance Program (CAP), send proof of earnings, other income, and child care costs for _________________________, __________________________, __________________________.

SECTION 2: Have there been any other changes (read boxes below) since your last Report, or do you expect any changes?

□ Your household moved (Write the new address below.)

□ Someone moved into or out of your household (Write who moved and when and new amount of rent.) □ Your rent went up or down (Write new rent amount.)

□ Someone started or left work (Write who, when, and where they started or left work.) □ Someone had a change in the amount of their unearned income.

□ Your child care costs (cost you pay not child care subsidy) are new or changed or child care provider changed (Write new amount and who

provides the child care.)

□ Someone is pregnant (Write who and expected delivery date, if known.) □ Death or Birth of someone in the household (Write who and when.)

□ Change in legally obligated child support paid by a member of your household (Write who in your household pays the support.) □ Other changes that may affect benefits (Write who, what, and when change occurred and give proof, if possible.)

Write the details of your change(s) here, and if you have proof send it in:

CERTIFICATION: I understand that the information I provide on this report may result in changes in my assistance, including reducing the amount of my Temporary Assistance Benefits, SNAP Benefits, Child Care Benefits or closing my case. I am aware that Federal and State Law provide for fine and/or imprisonment of any person who fraudulently attempts to receive, or fraudulently receives Temporary Assistance, Medicaid, Child Care or SNAP Benefits to which the person is not entitled. Information reported on this form may affect my eligibility for Medicaid.

I understand that I must contact my worker to report any changes that occur for my Temporary Assistance and Medicaid case within 10 days.

I understand that I must contact my worker immediately if any changes occur that affects my child care. I also understand that if I use a child care provider who is not licensed or registered, my provider must meet certain requirements in order to be paid.

For my SNAP case, I must report changes on the Periodic Report and at Recertification, whichever occurs first. I may also report changes at any other time.

IMPORTANT- YOU MUST SIGN AND RETURN THIS FORM. IF YOU CHECKED “YES” TO ANY CHANGES IN SECTION 2, MAKE SURE YOU CHECKED (√) THE BOX(ES) AND GAVE MORE DETAIL. IF THIS REPORT IS NOT COMPLETE, WE WILL SEND YOU A DISCONTINUANCE NOTICE.

Fill Out & Return In The Envelope Provided

When you return this Report, make sure you can see this address in the