Periodic Report - Online Resource Center

FAMILY INDEPENDENCE ADMINISTRATION
Matthew Brune, Executive Deputy Commissioner
James K. Whelan, Deputy Commissioner Stephen Fisher, Assistant Deputy Commissioner
Policy, Procedures, and Training Office of Procedures
POLICY DIRECTIVE #12-16-ELI
(This Policy Directive Replaces PD #02-41-ELI and PB #04-116-OPE)
FOOD STAMP CHANGE REPORTING RULES AND PERIODIC REPORTING
Date:
June 13, 2012
HAVE QUESTIONS ABOUT THIS PROCEDURE?
Call 718-557-1313 then press 3 at the prompt followed by 1 or
send an e-mail to FIA Call Center Fax, or fax to (917) 639-0298
Distribution: X
Subtopic(s):
Food Stamps
AUDIENCE The instructions in this policy directive are for Non Cash Assistance
Food Stamp (NCA FS) Center staff and Income Clearance Program
(ICP) staff. They are informational for all other staff.
POLICY Households in receipt of Food Stamp (FS) benefits, are subject to
change reporting requirements as follows:
See PB #04-105-ELI for
NYSNIP information.
See PD #10-03-ELI for
Transitional Food Stamp
Benefit information.
New York State Nutrition Improvement Project (NYSNIP)
Households in receipt of NYSNIP benefits have 48 month
certification periods and are not required to report any changes
during the certification period. However, these households are sent a
NYSNIP Food Stamp Benefits Interim Report (NYC) (LDSS-4836
NYC) at the end of the 23rd month of their certification period which
must be completed and returned by the tenth day of the 24th month
of their certification period, regardless of whether or not the
household has any changes to report. If the NYSNIP household
incurs a change that will increase their FS benefit, the change must
be acted on if verification of the change is provided.
Transitional Food Stamp Benefits
Households in receipt of Transitional Food Stamp Benefits (TFSB)
are not required to report any changes during their five month
transition period. TFSB households may report changes during the
transition period that will result in an increase in FS benefits, but the
household is required to file a new recertification application and be
recertified before any increase in FS benefits can be authorized
during the five month transition period.

See PB #08-01-ELI for
information on change
reporting households.
Ten Day Change Reporting Households
PD #12-16-ELI
The following non-NYSNIP and non-TFSB households are subject to
the ten day FS change reporting rules that require households to
report certain changes within ten days after the end of the month in
which the change occurred.
• Households in which all adults are elderly or disabled without
earned income
• Migrant or seasonal farm worker households
• Homeless (undomiciled – shelter code 23) households
• Households with no income (earned or unearned)
• Households certified for less than four months
• Group home residents in receipt of Supplemental Security
Income (SSI) or Social Security Disability (SSD)
Households subject to ten day FS change reporting rules are
required to report the following changes within ten days after the end
of the calendar month in which the change occurred:
• Changes in any source of income for anyone in the household
• Changes in the household’s total earned income when it
increases or decreases by more than $100 per month
• Changes in the household’s total unearned income from a
private source when it increases or decreases by more than
$100 per month
• Changes in the household’s total unearned income from a
public source when it increases or decreases by more than
$50 per month
• Changes in household composition
• Changes in residence
• Changes in rent or mortgage for households that move to a
new residence
• Changes in the amount of court-ordered child support that the
household is required to pay for a child residing outside of the
FS household when it increases or decreases by more than
$50 per month
• For households subject to the resource limit, any change that
will cause the household to exceed the resource limit
FIA Policy, Procedures, and Training 2 Office of Procedures

See PB #08-13-OPE for
information on six-month
reporting rules for FS
households.
BACKGROUND
The Periodic Report
(LDSS-4310) must be
signed, completed, and
returned even if the
household has no
changes to report.
Six-month Reporting Households
PD #12-16-ELI
All other non-NYSNIP, non-TFSB, and non-ten day FS change
reporting FS households are six-month reporters and are subject to
six-month reporting rules. These households will be mailed a
Periodic Report (LDSS-4310) in the fifth month of their twelve month
certification period which they must complete, sign, and return by the
tenth day of the sixth month of their certification period.
Except at recertification and on the Periodic Report, the only two
changes that six-month reporting households must report are if the
household’s gross income exceeds 130% of the poverty level and if
the household contains an Able Bodied Adult Without Dependents
(ABAWD) and the ABAWDs work hours go below 80 hours per
month. Either of these changes must be reported within ten days
after the end of the calendar month in which the change occurred.
FS households that are subject to six-month reporting rules are sent
the Important Information About What Changes You Must Report For
Food Stamps (LDSS-4791) each year, which lists the monthly,
weekly, and bi-weekly 130% poverty levels for their household size.
This policy directive provides instructions regarding the processing of
Periodic Reports for NCA FS households.
Effective May 2008, the certification period for NCA FS households
subject to six-month reporting rules was extended from six months to
twelve months. However, in order to comply with reporting rules that
were previously met by semiannual recertifications, these
households are required to complete, sign, and return a State issued
Periodic Report in the sixth month of their twelve month certification
period.
All NCA FS households subject to six-month reporting rules that
have a twelve-month certification period will be mailed the Periodic
Report on or about the Monday following the third Saturday of the
fifth month of their certification period. The FS household must
complete, sign, and return the Periodic Report by the tenth day of the
sixth month of their certification period (to be considered timely) even
if the household has no changes to report.
The processing of a failure to complete, sign, or return the Periodic
Report will result in a timely closing notice being sent to the
household. The closing notice will include the Follow-Up to the
Periodic Report (LDSS-4310A) and a postage paid return envelope.
FIA Policy, Procedures, and Training 3 Office of Procedures

What happens if the
household moves into an
exempt category during
a six-month cycle?
See PD #11-11-EMP for
the TALX procedure.
See PD #09-43-SYS and
PB #11-39-SYS for RFI
processing information.
PD #12-16-ELI
If the household completes, signs, and returns a Periodic Report or a
Follow-Up to the Periodic Report prior to the case actually closing,
the closing action must be settled in conference (SIC).
However, although the closing process may begin on the eleventh
day of the sixth month of the certification period for FS households
who fail to return the Periodic Report in a timely manner, the
household has until the last day of the sixth month of the certification
period to comply to avoid a loss of FS benefits and a need to reapply
for continued FS benefits.
For example, a FS household is mailed a Periodic Report on April
23rd and fails to return the Periodic Report by May 10th as
instructed. On May 11th, a closing action is initiated that generates a
Notice of Intent (NOI) to close the FS case. The FS household fails
to resolve the issue during the NOI period and the FS case closes on
May 25th. On May 30th, the FS household submits a completed and
signed Periodic Report. The closed FS case must be re-opened and
any lost FS benefits must be issued. However, if the FS household
fails to submit a completed and signed Periodic Report by May 31st,
the household must reapply to receive continued FS benefits.
Once a case has been placed on a six-month reporting cycle, the
household remains subject to the six-month reporting rules,
regardless of circumstances, until the next recertification.
For example, a household with a twelve month certification period
that is subject to the six-month reporting rules loses all of its income
during the certification period. The budget can be adjusted whenever
the household verifies the loss of income, but the household is still
subject to the six-month reporting rules (including the return of a
signed and completed Periodic Report) until the end of the
certification period. At that point, if the household still has no income,
the case will become subject to ten day change reporting rules.
ICP Web System
To further enhance this process, Management Information Systems
(MIS) has developed the ICPWeb system that serves as a tracking
mechanism used by ICP staff to enter information concerning
Periodic Reports received and those returned as undeliverable. The
ICPWeb also performs TALX and Resource File Integration (RFI)
matches on all cases sent a Periodic Report. Instructions on how to
access and enter information into the ICPWeb system are contained
in the ICPWeb Instructions (Attachment A).
FIA Policy, Procedures, and Training 4 Office of Procedures

REQUIRED
ACTION
BULKING process.
PD #12-16-ELI
The ICPWeb passes files directly to the Welfare Management
System (WMS) to initiate case closings for households that fail to
comply with the periodic reporting process and to SIC pending
periodic reporting closings for households that return a signed and
completed Periodic Report before the case actually closes.
For households that fail to return the Periodic Report in a timely
manner, the ICPWeb sends a file to WMS to initiate a case closing
using closing code E50 (Failed to Return 6 Month Periodic Report).
For Periodic Reports returned by households, ICP staff must scan
and index the Periodic Report and any enclosed documentation into
the ICPWeb. Periodic Reports returned by the Post Office as
undeliverable and the envelope stamped as “undeliverable” must
also be scanned and indexed into the ICPWeb. After scanning and
indexing, ICP staff reviews the Periodic Report for completeness and
signature so they can make the appropriate selections in the
ICPWeb. ICP staff will also data enter the household’s written
responses to the questions on the Periodic Report into the ICPWeb.
The ICPWeb contains a function labeled BULK RECEIVE, which
allows ICP staff to data enter the receipt of Periodic Reports into the
ICPWeb by solely entering the case number and whether or not the
Periodic Report is signed and completed. The bulking process allows
for a faster decontrol of the Periodic Reports that may be necessary
to ensure that households that return a Periodic Report in a timely
manner are not included in the file sent by the ICPWeb to WMS to
initiate a case closing for failure to return the Periodic Report.
For cases that have undergone the bulking process, the temporarily
delayed scanning, indexing, and data entry of the household’s
responses on the Periodic Report, must be completed by ICP staff in
a timely fashion to allow sufficient time to process any required
budgetary changes by the seventh month of the household’s
certification period.
The following sections in this procedure list the process for handling
Periodic Reports that are:
• Returned unsigned
• Returned incomplete
• Returned signed and completed
• Returned by the Post Office as undeliverable
• Hand delivered to the Food Stamp Center
FIA Policy, Procedures, and Training 5 Office of Procedures

Periodic Reports Returned Unsigned
ICP:
PD #12-16-ELI
ICP staff must select “Incomplete” in response to the question “Is the
Recertification/Eligibility Questionnaire?” After selecting “Incomplete”
the statement “Reasons for Incomplete” will appear and ICP staff
must select “Incomplete Signature”.
ICP Web:
Based on this response, the ICPWeb will send a file to WMS to close
the case using closing code E52 (Failure to Complete 6 month
Periodic Report – Signature).
Periodic Reports Returned Incomplete
Periodic Reports are incomplete if the household failed to answer the
questions on the report. Additionally, if the household answered
“Yes” to the question “Have there been any other changes since your
last Report, or do you expect any changes?” but failed to check any
of the checkbox options below it, the report is considered incomplete.
ICP:
ICP staff must select “Incomplete” in response to the question “Is the
Recertification/Eligibility Questionnaire?” The statement “Reasons for
Incomplete” will appear and ICP staff must select “Incomplete
Questionnaire”.
Note: If the Periodic Report is returned both unsigned and
incomplete, select the option “Incomplete Signature”.
ICPWeb:
Based on this response, the ICPWeb will send a file to WMS to close
the case using closing code E51 (Failure to Complete 6 month
Periodic Report–Questions).
FIA Policy, Procedures, and Training 6 Office of Procedures

Periodic Reports Returned Signed and Completed
ICP:
PD #12-16-ELI
In the ICPWeb, ICP staff must select “Complete” in response to the
question “Is the Recertification/ Eligibility Questionnaire?” After
selecting “Complete”, the question “Is the Periodic report with No
Change & No Document?” will appear. ICP staff must select “Yes” if
there are no changes and no enclosed documentation or “No” if
there are any changes and/or any enclosed documentation.
ICPWeb:
The ICPWeb will transmit the information entered by ICP staff into
the Food Stamp Paperless Office System (FS POS). If there is a
closing clocking down for failure to comply with the periodic reporting
process, the ICPWeb will pass a file to WMS to SIC the closing.
NCA FS Center 25:
Information concerning the Periodic Report that is loaded by the
ICPWeb into FS POS will appear in the new “NCA Periodic Mailer”
queue in the FS Change Case Data window and will be handled by
workers at the Special Projects Food Stamp Change Center (F25).
NCA Periodic Mailer Queue in FS POS
FIA Policy, Procedures, and Training 7 Office of Procedures

Decrease in FS benefits
PD #12-16-ELI
The Changes to the Active FS Case window in the FS Change Case
Data activity was updated to accommodate this process.
Supervisors at F25 will assign the cases that are loaded into the
NCA Periodic Mailer queue to the Workers at F25 who will:
• review the data loaded into FS POS for each Periodic Report
• review a copy of the Periodic Report and any documentation
submitted by the household in the HRAViewer
• review any TALX and/or RFI match information which is
located in the FS Change Case Data window
• determine if any changes need to be made in WMS
Periodic Reports With No Changes
If the F25 Worker determines that there are no changes on the case,
he/she will input a comment in FS POS that the household complied
with the periodic reporting process and there were no changes on
the case. A new WMS budget is not required for no change cases.
Processing Periodic Reporting Changes
Information submitted on or with a signed and completed Periodic
Report that will result in a decrease or termination of FS benefits
must be processed (even if the change is not verified) unless the
change is due to a decrease in a simplified deduction. Simplified
deductions are non-move shelter expenses, medical or dependent
care expenses.
FIA Policy, Procedures, and Training 8 Office of Procedures

Increase in FS benefits
Reported change that
will increase FS benefits
not verified.
Do not close the FS
case for failure to
provide documentation.
PD #12-16-ELI
Households whose FS benefits will be reduced or terminated as a
result of information submitted on or with a signed and completed
Periodic Report are only entitled to receive adequate notice. To
ensure that a timely notice is not provided in these instances, the
Worker must enter code A (manual notice – adequate action) in the
M3E Indicator field (element 053) on the Turn-Around-Document
(LDSS-3517), when taking an action that will reduce or terminate the
household’s FS benefits.
Households whose FS benefits would increase as a result of
information submitted on the Periodic Report (e.g. a decrease in
income, an increase in expenses, or an increase in household size),
cannot receive an increase in FS benefits until verification of the
change has been provided.
If the household did not include documentation to verify a change
reported on the Periodic Report that would result in an increase in
FS benefits, the Worker must mail the household the Notice of
Documentation Required – Change in Household Circumstances
(W-132S) which informs the household that they must verify any
changes that will entitle them to an increase in FS benefits.
Along with Form W-132S, the Worker must mail the household the
Eligibility Factors and Suggested Documentation Guide (W-119D)
and a postage paid return envelope addressed to the household’s
Home Center.
Households that return a signed and completed Periodic Report in a
timely manner are considered to have complied with the periodic
reporting process and are not to be closed for failure to submit
documentation with the Periodic Report.
As a household’s FS case cannot be closed for failure to submit
documentation along with the Periodic Report, the FS Worker at F25
is to complete the case without applying the unverified changes if
those changes would have resulted in an increase in FS benefits.
The FS Worker must enter a comment in FS POS that the case was
processed without applying the changes because the household
failed to include verification of the changes that would have
increased the household’s FS benefits. If the FS household submits
verification of the changes at a later date, the changes will be acted
upon by the Home Center.
FIA Policy, Procedures, and Training 9 Office of Procedures

Address on the Periodic
Mailer does not match
the address listed in the
ICPWeb.
See PB #12-15-SYS for
new Food Stamp Settle
in Conference Activity in
FS POS.
PD #12-16-ELI
Once the FS Worker at F25 has completed all the required actions
for the periodic reporting process, the case will be forwarded to the
supervisor’s queue. The Supervisor at F25 will:
• review the case (using the Approve FS Change Case Data
activity in FS POS Centers) to ensure that all required actions
were taken; and
• complete the approval process in a timely manner to ensure
that any change in FS benefits or closing action is effective for
the seventh month of the household’s certification period.
Periodic Reports Returned as Undeliverable
ICP:
ICP staff must select “Undelivered” in response to the question “Is
the Recertification/ Eligibility Questionnaire?” After selecting
“Undelivered”, two separate text boxes will appear, the first
containing the case address that the Periodic Report was mailed to
and the second containing the current address in WMS. In response
to the question “Is case Address and WMS Address different?” select
“Yes” if they are different and “No” if they are the same.
ICPWeb:
If ICP staff selected “No” (address is the same) the case will be
included in the file ICP passes to WMS of cases that fail to respond
to the Periodic Report in a timely manner. If ICP staff selected “Yes”
(address is different) the ICPWeb will transmit the information to FS
POS and will not include the case in the file ICP passes to WMS of
cases that fail to respond to the Periodic Report in a timely manner.
NCA FS Center 25:
If ICP staff selected “Yes” (address is different), the FS Worker at
F25 will make sure that the address in WMS is correct by matching it
against the documentation in the HRA Viewer. If the address in WMS
is correct, the Worker will mail the household a new LDSS-4310 and
a postage paid return envelope. The LDSS-4310 must be annotated
with a due date of at least ten calendar days from the mailing date. A
comment should be made in FS POS that a new Periodic Report
was mailed because the previously mailed report was sent to a prior
address. If an E50 closing is clocking down, process an SIC and if
the case is already closed with code E50, re-open the case.
FIA Policy, Procedures, and Training 10 Office of Procedures

Participant brings the
Food Stamp Periodic
Report to his/her Food
Stamp Center
Case is active
Household submits the
Periodic Report before
the end of the sixth
month of the certification
period.
PD #12-16-ELI
If the household returns a signed and completed Periodic Report by
the new date, the FS Worker at F25 will:
• review the Periodic Report and any documentation submitted
by the household;
• review any TALX and/or RFI match information
• determine if any changes need to be made
If any changes need to be made in WMS, process the required
actions in FS POS. If the household’s FS benefits will be terminated
or reduced as a result of information submitted on or with the
Periodic Report, only provide the household adequate notice.
If the household fails to return the LDSS-4310 by the new due date,
the FS Worker at F25 will close the case using closing code E50.
Periodic Reports Hand Delivered to the Food Stamp Center
If an individual brings a Periodic Report to a Food Stamp Center, the
Front Door Receptionist (FDR) will give the individual a ticket to FS
Reception/NCA General. In Non-Model Offices the individual will go
directly to the FS Receptionist.
The FS Receptionist will make sure that the individual has properly
signed and completed the Periodic Report and will check WMS to
determine the current status of the case.
If the case is active, the FS Receptionist will give the signed and
completed Periodic Report to the designated Worker who will scan
and index the Periodic Report and any enclosed documentation.
The ICPWeb will retrieve the scanned and indexed Periodic Report
and any supporting documentation that was also scanned and
indexed at the same time and will place the information into a queue
for ICP staff to process. The ICPWeb has been updated to allow ICP
staff to enter information contained on these Periodic Reports into
the ICPWeb. The ICPWeb will transmit the information entered by
ICP staff into FS POS for F25 processing. If a closing is clocking
down for failure to comply with the periodic reporting process, the
ICPWeb will pass a file to WMS to SIC the closing.
If the case is closed for failure to comply with the periodic reporting
process, but the household has submitted the signed and completed
Periodic Report to the Home Center before the end of the sixth
month of the household’s certification period, the Periodic Report
and any attached documentation must be given to the Home
Center’s Mail Processing Unit to process the re-opening of the case.
FIA Policy, Procedures, and Training 11 Office of Procedures

Household submits the
Periodic Report after the
end of the sixth month of
the certification period.
PROGRAM
IMPLICATIONS
PD #12-16-ELI
If the case is closed for failure to comply with the periodic reporting
process, and the household submits a Periodic Report to the Home
Center after the end of the sixth month of the certification period, the
FS Receptionist must inform the individual that he/she must reapply
to receive continued FS benefits.
POS Implications Workers are to make all required changes and closing actions
through FS POS in the FS Change Case Data activity.
Medicaid
Implications
LIMITED ENGLISH
PROFICIENT (LEP)
AND HEARING
IMPAIRED
IMPLICATIONS
FAIR HEARING
IMPLICATIONS
There are no Medicaid implications.
For Limited English Proficient (LEP) and hearing-impaired
participants, make sure to obtain appropriate interpreter services in
accordance with PD #11-33-OPE and PD #08-20-OPE.
Avoidance/ Ensure that all case actions are processed in accordance with
Resolution
current procedures and that electronic case files are kept up-to-date.
Remember that participants must receive either adequate or timely
and adequate notification of all actions taken on their case.
Conferences If a participant comes to the FS Center and requests a conference,
the Receptionist must alert the Center Director’s designee that the
participant is to be seen. If the participant contacts the Worker
directly, advise the participant to call the Center Director’s designee.
In Model Centers, the Receptionist at Main Reception will issue an
NCA General ticket to the participant to route him/her to NCA FS
Reception. The NCA FS Receptionist will issue a Conf/Appt/Problem
ticket and verbally alert the FS Center Director’s designee.
The designee will listen to, evaluate and review the participant’s
complaint regarding the FS case. The designee is responsible for
ensuring that further appeal by the participant through a Fair Hearing
request is properly controlled and that the appropriate follow-up
action is taken in all phases of the Fair Hearing process.
FIA Policy, Procedures, and Training 12 Office of Procedures

PD #12-16-ELI
All conferences concerning the periodic reporting process will be
handled at the participant’s Food Stamp Center. If the participant
submits documentation during the conference that is sufficient to
terminate a pending closing, the designee will image and index the
Periodic Report and any documentation submitted and process an
action to SIC the case.
Evidence Packets For Fair Hearing purposes, all evidence packets must contain a copy
of the Periodic Report and any other documentation submitted by the
participant in order to help support the Agency’s action.
REFERENCES Food Stamp Source Book (FSSB), pages 302-310
01-ADM 09
01-ADM 14
02-ADM 07
04-ADM 02
07-ADM 05
7 CFR 273.12(a) (5)
18 NYCRR 387.17 (d) and (e)
GIS 01 TA/DC010
GIS 04 TA/DC018
RELATED ITEMS
PB #04-105-ELI
PB #08-01-ELI
PB #08-13-OPE
ATTACHMENTS Attachment A
� Please use Print on
Demand to obtain copies
of forms.
LDSS-4310
LDSS-4310A
LDSS-4791
LDSS-4836 NYC
W-132S
W-132S (S)
ICPWeb Instructions
Food Stamp Periodic Report (Rev. 4/07)
Follow-Up to the Periodic Report (Rev. 4/07)
Important Information About What Changes You
Must Report For Food Stamps (Rev. 2/03)
NYSNIP Food Stamp Benefits Interim Report
(NYC) (Rev. 11/11)
Notice of Documentation Required – Change in
Household Circumstances (Rev. 3/8/12)
Notice of Documentation Required – Change in
Household Circumstances (Spanish)
(Rev. 3/8/12)
FIA Policy, Procedures, and Training 13 Office of Procedures

Attachment A
ICPWeb Instructions
Sign onto the HRA Intranet and select “Web Program Applications”.
Select Web Program
Applications
On the Web Based Applications page select “Income Clearance Program (ICP web) –
Production”.
Select Income Clearance
Program (ICP web) –
Production

Attachment A
After you have scanned a Periodic Mailer or a batch of Periodic Mailers, select SCAN & INDEX.
Select
SCAN & INDEX
The Periodic Mailer(s) that you have scanned will appear in your scan and index folder. Select the case
number of the Periodic Report that you are ready to index (and data enter) into the ICPWeb. After selecting
the case number, click on “Proceed to Next Screen”.
Select the case number of
the Periodic Report that
you are ready to index.
Select Proceed to Next Screen
after selecting the case number.

Attachment A
Select the pages belonging to a document and then click “add selected pages to document”.
Select add selected
pages to document
Select the page
number of the
document.
Select Proceed
to Next Screen.
On the right hand side of the screen you will see the documents that were just created. In the screenshot
below, 2 documents were created. Select “Proceed to Next Screen”.
Select Proceed
to Next Screen.
2 documents
were created.

Attachment A
The case number appears. Click Search and match the details with the Periodic Report to make sure that it
was scanned under the correct case number.
Click Search.
The case number and demographic data come up. Click on search and match the details with the Periodic
Report to make sure it is scanned under the correct case number. Select the document type and then click
“Preview” to see the document in the Preview field. After the documents have been checked, click “Next”.
Click Next
Select the
Document Type

Attachment A
Determine if the Periodic Report is complete, incomplete, or undelivered and make the appropriate
selection. If the Periodic Report is unsigned, select Incomplete.
Select Complete, Incomplete, or Undelivered.
If Incomplete is selected, the statement Reasons for Incomplete will appear. Select Incomplete
Signature if the report is unsigned or Incomplete Questionnaire if the report is incomplete. If the report is
both unsigned and incomplete, select Incomplete Signature.
If the Periodic Report is
incomplete or unsigned
select Incomplete.
In the drop down line select
Incomplete Questionnaire or
Incomplete Signature.

Attachment A
If Undelivered is selected, the case address on the report and the WMS address will appear. Answer the
question Is case address and WMS address different. If different select Yes, if the address is the same
select No.
Select Yes if the addresses
are different, No if the
addresses are the same.
If Complete is selected, click “Yes” if there are no changes and no enclosed documentation and select
“No” if there are any changes and/or any enclosed documentation.
Select Yes or No.

Attachment A
Data enter the information listed on Sections 1 and 2 of the Periodic Report onto the corresponding location
on the ICPWeb page.
Enter Section 1data.
Enter Section 2 data

LDSS-4310 (Rev. 4/07)
LDSS
ADDRESS
CITY, STATE ZIP
Periodic Report
You must fill out this Report and return it to the address listed on the back by
REPORT DUE DATE to continue getting benefits.
WHEN YOU RETURN THIS
REPORT, MAKE SURE THAT THE
LOCAL DISTRICT ADDRESS
ON THE BACK OF THIS REPORT
SHOWS IN THE RETURN
ENVELOPE WINDOW.
CASE NAME
ADDRESS
CITY, STATE ZIP
This “Periodic Report” helps us to gather information about any changes you may have had since the last time you were in contact
with your eligibility worker. Please make sure to read and follow all the instructions before filling out this “Periodic Report”. It is
important for you to complete, sign and return this “Periodic Report” by the due date listed above. Failure to do so may result in
your Child Assistance (CAP), Child Care, and/or Food Stamp Benefits being discontinued.
CASE NAME
OFFICE
CASE NAME
OFFICE
If you have any questions on how to fill out
this Report, call :( ) PHONE NUMBER
UNIT
CASE NUMBER
WORKER
CASE NUMBER
UNIT
WORKER
We must get your completed Report by REPORT DUE DATE. If we don’t get
the completed Report by this date, your Child Assistance (CAP), Child Care
and/or Food Stamp Benefits will stop. Failure to return this report will not
affect your Medicaid coverage.
General Instructions
1. You must answer all questions on this Report. Answer all questions on this Report for everyone who is getting, or
anyone who is legally responsible for someone getting, Child Assistance (CAP), Child Care, and/or Food Stamp
Benefits.
2. Do not sign this Report any sooner than SIGNATURE DATE. If you do, this report is not considered complete.
3. You must complete this Report and return it to the address on the back of this report by REPORT DUE DATE, or your
Child Assistance (CAP), Child Care or Food Stamp Benefits may be reduced or closed.
Reminder: If you are also receiving Temporary Assistance and Medicaid, you must report any changes to your
worker within 10 days. For Food Stamp Benefits, you must report within ten days after the end of the month if your total
monthly gross income exceeds the 130% limit you have been given. Otherwise, you do not need to report changes at any
time other than on this Periodic Report or at Recertification, whichever occurs first. You must contact your worker
immediately if any changes occur that affect your Child Care.
LDSS-4310 (Rev. 4/07)

SECTION 1: Please list ALL income for EACH household member. If you are only receiving food stamp 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])
Who
Name of Employer or Other
Source of Income
How Often?
(Daily, Weekly,
Bi-Weekly, Monthly)
Total # of Hours
Worked Per Week
REPORT MONTH
Send in proof of all income that any household member got during the entire month of REPORT MONTH.
If CAP INDICATOR IS PRESENT, THE FOLLOWING SENTENCE WILL REPLACE THE SENTENCE ABOVE:
Since you participate in the Child Assistance Program (CAP), send proof of earnings, other income, and child care costs
for 1 ST Month of Report Qtr, 2 ND Month of Report Qtr, and 3 RD Month of Report Qtr.
SECTION 2: Have there been any other changes (read boxes below) since your last Report, or do you expect any changes?
No □ or Yes □ If Yes, you must check (√) at least one of the boxes below.
□ 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 or child care provider changed (Write new amount and who provides the child care.)
□ Your need for child care has changed due to a change in your work schedule or other reason. (Explain what has changed)
□ A change in contribution or subsidy (Write what the contribution is and new amount.)
□ 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, Food Stamp 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 Food Stamp 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 Food Stamp Benefits 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 DATE THIS FORM NO SOONER THAN SIGNATURE DATE. 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.
Your Signature: Date: Telephone Number (daytime)
Fill Out & Return In The Envelope Provided
When you return this Report, make
sure you can see this address in the
return envelope window �
LDSS
OFF/UNIT/WKR
ADDRESS
ADDRESS
CITY, STATE ZIP

LDSS-4310A (Rev. 4/07)
FOLLOW-UP TO THE PERIODIC REPORT
CASE NAME CASE NUMBER OFFICE/ UNIT NUMBER
WORKER NUMBER
If you have any questions on how to fill out
this Report, call:
WORKER NAME (CASELOAD)
We must get your completed Report by ___________________. If we don’t
get the completed Report by this date, your Child Assistance (CAP), Child
Care and/or Food Stamp Benefits will stop. Failure to return this report will
not affect your Medicaid coverage.
General Instructions
1. You must answer all questions on this Report. Answer all questions on this Report for everyone who is
getting, or anyone who is legally responsible for someone getting, Child Assistance (CAP), Child Care,
and/or Food Stamp Benefits.
2. Do not sign this Report any sooner than ________________. If you do, this report is not considered
complete.
3. You must complete this Report and return it to the address on the front of the enclosed notice by
_______________, or your Child Assistance (CAP), Child Care or Food Stamp Benefits may be reduced or
closed.
Reminder: If you are also receiving Temporary Assistance and Medicaid, you must report any changes to
your worker within 10 days. For Food Stamp Benefits, you must report within ten days after the end of the
month if your total monthly gross income exceeds the 130% limit you have been given. Otherwise, you do not
need to report changes at any time other than on this Periodic Report or at Recertification, whichever occurs
first. You must contact your worker immediately if any changes occur that affect your Child Care.
SECTION 1: Please list ALL income for EACH household member. If you are only receiving food
stamp 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])
Who
Name of Employer or Other
Source of Income
How Often?
(Daily, Weekly,
Bi-Weekly Monthly,)
Total # of Hours
Worked Per Week
“Report Month”
Send in proof of all income that any household member got during the entire month of
_____________. (Report Month)
Child Assistance Program (CAP) cases must send in proof of earnings, other income, and child
care costs for the months of _____________, _____________, and ______________. (Report Quarter)

LDSS-4310A (Rev. 4/07) REVERSE
SECTION 2: Have there been any other changes (read boxes below) since your last Report, or do you
expect any changes?
No □ or Yes □ If Yes, you must check (√) at least one of the boxes below.
□ 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 or child care provider changed (Write new amount and who provides the child
care.)
□ Your need for child care has changed due to a change in your work schedule or other reason.
(Explain what has changed)
□ A change in contribution or subsidy (Write what the contribution is and new amount.)
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, Food Stamp 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 Food Stamp 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 Food Stamp Benefits 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 DATE THIS FORM NO SOONER THAN ___________________.
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 COMPLETED, WE WILL SEND YOU
A DISCONTINUANCE NOTICE.
Your Signature:
Date: Telephone Number (daytime)

LDSS-4791 (Rev. 2/03)
IMPORTANT INFORMATION ABOUT
WHAT CHANGES YOU MUST REPORT FOR FOOD STAMPS
Esta carta está traducida al español en la página 2
General Telephone No. for Questions or Help: ___________________________
New Food Stamp Program rules make it easier for households with income to report changes that may affect
eligibility or benefit levels.
As a household with income, you are only required to report changes about your Food Stamp household at the
time of your next recertification, with two exceptions:
If your household’s gross monthly income is more than $____________ (130% of the poverty level) you must
report this monthly amount to your social services district by phone, in writing, or in person within 10 days after
the end of the month. Gross income is the amount of income before taxes and other deductions are taken out,
not the amount you receive when you cash your check. We must use the gross income in figuring your
eligibility for food stamps.
Any income that you receive must be added together to know if you are over 130% of the poverty level.
Examples of income that count include earnings, child support payments, Unemployment Insurance, temporary
assistance payments, Workers Compensation or disability payments such as Social Security, SSI or private
disability payments.
For example, if your only income is from earnings, you are paid weekly and your gross income is over $
___________ a week, or if you are paid biweekly and your gross income is over $______________ biweekly,
you must report this to us within 10 days after the end of the month. When you add up your earnings, to see if
you are over 130% of poverty, use your gross pay from the last four weeks of the month.
If you are an Able-Bodied Adult Without Dependents (“ABAWD”), you must tell us if your work hours go
below 80 hours a month. You must tell us this within 10 days after the end of the month when your work hours
fell below 80 hours.
If you have a six-month certification period, any other changes to your Food Stamp household including who
lives with you, rent costs, and gross income changes under 130% of the poverty level do not need to be reported
until your next six-month recertification.
If you only report once a year for recertification (12 month certification period), and do not receive Temporary
Assistance, you will be required to report your changes on one mail report received 6 months into your
certification period. You may still voluntarily report any change about your household and, if this change will
increase your benefit level and you verify this change, we will increase your benefit.
These changes apply only to the Food Stamp Program. If you also receive Temporary Assistance (TA), you are
still required to report changes for TA within 10 days of the change.
If you have questions about this new reporting requirement, or if your gross income exceeds the 130% poverty
level printed above, you may call the number printed at the top of this letter. Otherwise you will be required to
recertify at your next scheduled recertification date and can report any changes you have at that time.

LDSS-4791-SP (Rev. 2/03) REVERSO
INFORMACIÓN IMPORTANTE SOBRE LOS CAMBIOS QUE USTED DEBE REPORTAR COMO
BENEFICIARIO DE CUPONES DE ALIMENTOS
No. de teléfono general para hacer preguntas o pedir ayuda: _________________________
Nuevas reglas relacionadas al Programa de Cupones de Alimentos facilitan a hogares con ingresos el reportar
cambios que afectan los requisitos necesarios para obtener cupones de alimentos o la cantidad de beneficios que
el hogar recibe.
Si su hogar es un hogar que recibe ingresos, solamente se le requiere que reporte cambios pertinentes a al hogar
que recibe beneficios de Cupones de Alimentos cuando presenta una recertificación, con dos excepciones:
Si el ingreso mensual bruto de su hogar excede $____________ (130% del nivel de pobreza), usted debe
reportar esta cantidad mensual a su distrito de servicios sociales por teléfono, por escrito, o en persona, dentro
de 10 días de finalizar el mes. El ingreso bruto es la cantidad de ingresos antes de pagar impuestos y descontar
otras deducciones y no la cantidad que usted recibe cuando cobra su cheque. Nosotros debemos utilizar el
ingreso bruto al calcular si usted reúne o no los requisitos para recibir Cupones de Alimentos.
Cualquier otro ingreso que usted reciba debe ser agregado al ingreso total para determinar si usted sobrepasa el
130% del nivel de pobreza. Ejemplos de ingresos que tomamos en cuenta incluyen: ingresos, pagos de
manutención infantil, seguro por desempleo, pagos de asistencia temporal, compensación laboral o pagos por
incapacidad, tales como los del Seguro Social, SSI o pagos privados por incapacidad.
Por ejemplo, si su único ingreso proviene de ingresos, si se le paga semanalmente, y si su ingreso bruto excede
$__________ por semana, o si a usted se le paga cada dos semanas y su ingreso bruto excede $__________
cada dos semanas, usted nos debe reportar esto dentro de 10 días de finalizar el mes. Cuando usted suma sus
ingresos para determinar si sobrepasa el 130% del nivel de pobreza, utilice el salario en bruto recibido en las
últimas cuatro semanas del mes.
Si usted es un Adulto Capaz de Trabajar sin Dependientes (Able-Bodied Adult Without Dependents—
ABAWD), usted nos tiene que informar si sus horas de trabajo se reducen a menos de 80 horas al mes. Usted
nos debe informar esto dentro de 10 días contados a partir del fin del mes en el cual sus horas de trabajo
disminuyeron a menos de 80 horas de trabajo.
Si usted tiene una certificación por un período de seis meses, cualquier otro cambio que se efectúe en el hogar
que recibe Cupones de Alimentos, incluyendo las personas que viven con usted, costos de alquiler, y cambios en
los ingresos brutos inferiores al 130% del nivel de pobreza, no necesitan ser reportados hasta su próxima
recertificación de los seis meses.
Si su período de recertificación es de solamente una vez al año (certificación por un período de 12 meses), y no
recibe Asistencia Temporal a usted se le exigirá reportar sus cambios en un informe por correo que recibirá
cumplidos los seis meses de su período de certificación. Usted todavía puede reportar voluntariamente cualquier
cambio acerca de su hogar, y, si este cambio va a incrementar su nivel de beneficios y usted verifica este
cambio, nosotros aumentaremos su beneficio.
Estos cambios solamente se aplican al Programa de Cupones de Alimentos. Si usted también recibe Asistencia
Temporal (TA) todavía se le requiere reportar cambios pertinentes a la asistencia de TA dentro de 10 días de
efectuarse el cambio.
Si tiene alguna pregunta acerca de este nuevo requisito de reporte, o si su ingreso bruto excede el 130% del nivel
de pobreza indicado anteriormente, usted puede llamar al número de teléfono impreso en la parte superior de
esta carta. De lo contrario, usted tendrá que presentar una recertificación durante su próxima cita de
recertificación y podrá reportar cualquier cambio que tenga en ese momento.

LDSS-4836 NYC (Rev 11/11) New York State Office of Temporary and Disability Assistance
fold
NYSNIP Food Stamp Benefits Interim Report (NYC)
Notice Date:___________________________
Due Date:_____________________________
Please fill out this form right away and return it to the address listed above. If you don’t send the form back, we will
have to stop your food stamp benefits.
We’ve sent this form because we must update your NYSNIP food stamp benefits case. The law says we must do this every two years.
Please answer the questions below about your housing and utility expenses. These expenses affect how much you can get in food
stamps. If you never told us about your housing and utility costs, or if these costs have gone up, we might be able to give you more food
stamps.
Even if you have no changes to report, you must send the form back or your food stamp benefits will stop.
Please sign and date the form and return it to us no later than the 10 th day of next month.
You can respond by calling the SSI-FS Center Helpline at 718-722-4009.
QUESTIONS YOU MUST ANSWER
1. Do you pay more than $235 each month for rent or for mortgage payments, taxes and insurance on your property?□ Yes □ No
If you answered “Yes”, and have never sent us proof of these expenses, attach the proof now – such as a rent receipt, landlord
statement, mortgage payment, cancelled check or money order.
2. Do you live in either public or subsidized housing where heat is included in your rent? □ Yes □ No
3. Answer this question ONLY if you live in public or subsidized housing AND heat is included in your rent:
a. Do you pay a monthly excess charge to your landlord for air conditioning? □ Yes □ No
b. Do you pay an electric bill and use an air conditioner? □ Yes □ No
(If you answered “Yes” to either a. or b., and have never sent us proof of these expenses, attach the proof now – such as an electric bill,
landlord statement, or canceled check or money order.
APPLICANT’S SIGNATURE
X
DATE SIGNED
IMPORTANT INFORMATION
YOU MAY BE ENTITLED TO HIGHER BENEFITS
The maximum monthly Food Stamp Benefit for one person is $200. If you are receiving less than this amount, you MAY be eligible for
higher benefits, especially if ANY of the following applies to you:
You have more than $35 each month in unreimbursed medical expenses, that is, medical expenses that you yourself must pay and
that are not paid by Medicare, Medicaid, or any other health insurance.
Your rent is more than $425 per month.
If your monthly income decreases by $75 or more due to a reduction of your SSI grant.
If you have any of these circumstances and want to find out whether you might be able to get more Food Stamp Benefits or if you have
questions about how to fill out this form, call the SSI-FS Center Helpline at 718-722-4009 or call the State Food Stamp Hotline at 1-800-
342-3009. Thank you.
Make sure to return this report to the address listed above.
We are pleased that you participate in the Food Stamp Program and would like for you to continue to participate.
Remember, you can respond to this report by calling the SSI-FS Center Helpline at 718-722-4009.

Form W-132S LLF
Rev. 3/8/12
Please verify:
Date:
Case Number:
Case Name:
NCA FS Center:
Notice of Documentation Required – Change in Household Circumstances
Under food stamp rules, you must verify changes in your circumstances that entitle you to increased
benefits. You recently reported such a change to us, but you did not verify the change. We cannot increase
your benefits until you do so.
We have enclosed the Eligibility Factors and Suggested Documentation Guide (W-119D) that gives examples
of documents you can use to verify the change you reported. Photocopies are acceptable. Send the required
documentation in the enclosed self-addressed envelope right away so that your benefits are increased as
soon as possible.
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Income received by:
Presence in your household of:
Shelter expenses (e.g., rent or mortgage payments):
Child care or dependent care costs:
Medical expenses of:
Alien status of:
Other/Remarks:
Worker's Signature Date

Form W-132S (S) LLF
Rev. 3/8/12
Favor de comprobar:
Fecha:
Número del Caso:
Nombre del Caso:
Centro de
Cupones de Alimentos NCA:
Notificación de Documentación Solicitada – Cambio de Circunstancias en el Hogar
Conforme a las reglas de cupones para alimentos, usted tiene que comprobar cambios en sus circunstancias
que le dan derecho a un aumento de beneficios. Recientemente usted nos informó de tal cambio, pero no
comprobó el cambio. No podemos aumentarle sus beneficios hasta que usted así lo haga.
Hemos adjuntado la Guía de Factores de Elegibilidad y Documentación Sugerida (W-119D [S]), que
tiene ejemplos de documentos que puede usar para comprobar el cambio que reportó. Las fotocopias son
aceptables. Envíenos de inmediato la documentación solicitada en el sobre adjunto con dirección del remitente
para que podamos aumentarle sus beneficios tan pronto posible.
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Ingreso recibido por:
Residen en su hogar:
Gastos de alojamiento (p.ej., pagos de alquiler o hipoteca):
Gastos de Cuidado Infantil o de dependientes:
Gastos médicos de:
Estado de extranjero de:
Otro/comentarios:
Firma del Trabajador Fecha