Periodic Report - Online Resource Center

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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)
Page 1 and 2: FAMILY INDEPENDENCE ADMINISTRATION
Page 3 and 4: See PB #08-13-OPE for information o
Page 5 and 6: REQUIRED ACTION BULKING process. PD
Page 7 and 8: Periodic Reports Returned Signed an
Page 9 and 10: Increase in FS benefits Reported ch
Page 11 and 12: Participant brings the Food Stamp P
Page 13 and 14: PD #12-16-ELI All conferences conce
Page 15 and 16: Attachment A After you have scanned
Page 17 and 18: Attachment A The case number appear
Page 19: Attachment A If Undelivered is sele
Page 23 and 24: LDSS-4310A (Rev. 4/07) FOLLOW-UP TO
Page 25 and 26: LDSS-4791 (Rev. 2/03) IMPORTANT INF
Page 27 and 28: LDSS-4836 NYC (Rev 11/11) New York
Page 29: Form W-132S (S) LLF Rev. 3/8/12 Fav

Periodic Report - Online Resource Center

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