OCFS-LDSS-4779 NEW YORK STATE OFFICE OF CHILDREN AND ... · ocfs-ldss-4779 (rev. 09/2015) new york state office of children and family services approval of your application for child

OCFS-LDSS-4779 (Rev. 09/2015)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

APPROVAL OF YOUR APPLICATION FOR CHILD CARE BENEFITS NOTICE DATE:

EFFECTIVE ELIGIBILITY DATE

NAME AND ADDRESS OF AGENCY/CENTER OR DISTRICT OFFICE

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

1-800-342-3334

Record Access

Legal Assistance Information

OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

WORKER TELEPHONE NO.

Your application dated for child care benefits has been approved. You are eligible to receive child care

benefits for child care provided on through while you are

Comments:

YOU HAVE THE RIGHT TO A CONFERENCE AND/OR A HEARING TO APPEAL THIS DECISION

READ THE BACK OF THIS NOTICE ON HOW TO REQUEST A CONFERENCE AND/OR HEARING TO APPEAL THIS DECISION

BENEFITS. Payment will be provided on behalf of the following:

Child(ren): For this provider: For the amount of:** Full Time or Part Time:

**Payment may vary based on fluctuations in your approved activity and/or absences.

Benefits will be paid: Directly to you. Directly to your provider.

Your child care provider must submit a bill and attendance sheet to your local department of social services.

FAMILY SHARE. You are responsible for paying the following fees:

Effective , a Weekly Family Share must be paid to

in the amount of $ per week.

Effective , an Additional Family Share must be paid to


Effective , a Court Ordered Family Share must be paid to

in the amount of $ per week, for the child(ren) .

The following information is an explanation of how your weekly family share was determined.

Family’s annual gross income

St

$

Minus 100% annual state income standard for a family size of $

Remaining income $

Remaining income $ X family share % %

% = $

$ / 52 weeks = $ weekly family share

All family share amounts are rounded to the nearest $0.50. There is a minimum fee of $1 per week for all families not receiving TA.

In order to continue to receive benefits these are your responsibilities:

Notify your caseworker immediately of any change in family income, who lives in your house, employment, child care arrangements or other changes which may affect your continued eligibility or the amount of your benefit.

Promptly pay any family share required.

The LAW(S) AND/OR REGULATION(S) that allows us to do this is:

CLIENT/FAIR HEARINGS COPY

OCFS-LDSS-4779 (Rev. 09/2015) Reverse

RIGHT TO ACCEPT OR DECLINE SERVICES: Approval of your benefits does not obligate you to accept the services. You may choose to decline the services by contacting your local department of social services.

If you disagree with your local department of social services decision you may request a conference and/or a fair hearing.

1. CONFERENCE: You have a right to a conference with your local department of social services to review the determination. If you want a conference, you should request one AS SOON AS POSSIBLE, because the outcome of the conference may impact your decision to request a fair hearing. At the conference, you may present information to demonstrate why you believe the agency action is not correct.

You may request a conference by:

(1) Calling: (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL).

(1) (2) Writing: Check the box below and mail to

Please keep a copy for yourself.

I want a conference. I do not agree with the agency’s action. You may explain on a separate paper why you disagree, but you do not have to include a written explanation.

2. FAIR HEARING: You have a right to a fair hearing to appeal the determination of the local department of social services. If you want a fair hearing, you have 60 DAYS from the NOTICE DATE, located on the front page, to make the request. You can request a fair hearing without requesting a conference.

You may request a fair hearing by:

(1) Calling: 1-800-342-3334 (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL).

(2) Online: To send your fair hearing request online, go to http://www.otda.ny.gov/oah, click on the links to request a fair

hearing using the online form, and follow the instructions to complete and submit the form online.

(3) Writing: Check the box, complete the information below and mail to the New York State Office of Administrative

Hearings, Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York, 12201-1930. Please keep a copy for yourself.

(4) Faxing: Check the box, complete the information below and fax both sides of this form to (518) 473-6735.

I want a fair hearing. I do not agree with the agency’s action. You may explain on a separate paper why you disagree, but you do not have to include a written explanation.

Name: District:

Address: Case Number:

Phone Number:

If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay-stubs, receipts, child care bills, medical verification, letters, etc. that may be helpful in presenting your case.

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid

Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your

case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a conference or fair hearing, how to see your file, or how

to get additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice.

http://www.otda.ny.gov/oah

OCFS-LDSS-4780 (Rev. 09/2015)

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

DENIAL OF YOUR APPLICATION FOR CHILD CARE BENEFITS NOTICE DATE:


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



and assistance

1-800-342-3334

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


Your application dated for child care benefits has been denied and the reason(s) your application has

been denied are explained below.

Comments:



You are ineligible to receive benefits because:

Your family’s gross income exceeds 200% of the State Income Standard, which is the maximum income allowed

by New York State regulation to be eligible for child care subsidy. Your family’s monthly gross income of

$ exceeds the maximum monthly income of $ for a family size of .

(Please see the attached addendum for additional information)

You have not provided us with the following documents:

You are not programmatically eligible for child care services because:

Due to insufficient funding the district is not opening cases at this time.

Due to insufficient funding, the district is only opening cases up to % of the State Income Standard.

Your family’s monthly gross income of

Your family’s monthly gross income is

$ exceeds the maximum monthly gross income of

$ for your family size. Also, your family does not meet the eligibility criteria for a child care guarantee

designation. (Please see attached addendum for additional information)

Other:



OCFS-LDSS-4780 (Rev. 09/2015) REVERSE


1. CONFERENCE: You have a right to a conference with your local department of social services to review the determination. If

you want a conference, you should request one AS SOON AS POSSIBLE, because the outcome of the conference may impact your decision to request a fair hearing. At the conference, you may present information to demonstrate why you believe the agency action is not correct.



(2) Writing: Check the box below and mail to






(2) Online: To send your fair hearing request online, go to http://www.otda.ny.gov/oah, click on the links to request a fair hearing

using the online form, and follow the instructions to complete and submit the form online.

(3) Writing: Check the box, complete the information below and mail to the New York State Office of Administrative Hearings,

Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York, 12201-1930. Please keep a copy for yourself.



Name: District:


Phone Number:




ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a conference or fair hearing, how to see your file, or how to

get additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice.


OCFS-LDSS-4780 (Rev. 09/2015)

ADDENDUM TO DENIAL OF YOUR APPLICATION FOR CHILD CARE BENEFITS-FINANCIAL ELIGIBILITY CALCULATION

Effective Date:

Case Name:

Case Number:

We have determined that you are not eligible for child care benefits. Your family’s monthly gross income is $ .

This exceeds the maximum monthly gross income standard of $ for a family size of .

Please check the information below. If there is a mistake contact your caseworker listed on page one of this notice. If there is a mistake, it could mean that the decision made about your benefits is not correct.

There is a child with special needs residing in your household. Yes No If you have a child with special needs, that needs child care, you may have received this notice in error. Contact your caseworker on page one of this notice to determine if you were denied child care benefits in error.

Your family’s monthly gross income was determined from the following sources:

Wages or salary (18 NYCRR § 404.5(b)(5)(i)) before taxes in the amount of: $ per month.

Social Security (18 NYCRR §404.5(b)(5)(iv)) in the amount of: $ per month.

Child Support (18 NYCRR §404.5(b)(5)(xi)) in the amount of: $ per month.

*Other income not listed above as defined in New York State regulation

18 NYCRR §404.5(b)(5) in the amount of: $ per month.

Your family’s total monthly gross income: $ per month.

The following information is an explanation of how your eligibility for child care benefits was determined. To determine eligibility for child care benefits, your family’s monthly gross income for your family size was compared to the Social Service District’s (SSD) priority level for the monthly income standard. For a family to be eligible for child care benefits, a family must make less than the Monthly Income Standard amount listed below for their family size. Below are the Monthly Income Standards used by the district to determine your eligibility for child care benefits.

Family Size SSD’s Priority Level = %

Monthly Income Standard

1

2

3

4

5

6

7

8

For families with more than 8 persons, add $ for each additional person.

Your family’s monthly gross income is $ for a family size of . This exceeds the maximum of $ .

*Other income not listed above and defined in New York State regulation 18 NYCRR 404.5(b)(5) are defined as but not limited to the following: net income for non-farm self-employment, i.e. gross receipts minus expenses from one’s own business, professional enterprise or partnership; or net income from farm self-employment, i.e. gross receipts minus operation expenses from the operation of a firm by a person on his own account, as owner, renter or sharecropper; or dividends, interest (on savings or bonds) income from estates or trusts, net rental income or royalties; public assistance (PA) or welfare payments include PA payments such as SSI and home relief; or pensions and annuities include pensions or retirement benefits paid to a retired person or his survivors; or unemployment compensation, workers’ compensation; or alimony; or veterans’ pensions.

In addition to the citations listed on the attached notice refer to the district’s Child and Family Services Plan, at http://ocfs.ny.gov/main/childcare/plans/plans.asp for additional information on how the district closes cases in the event that there are insufficient funds to provide child care benefits to all eligible families and the order in which they will open new cases should funding become available.

http://ocfs.ny.gov/main/childcare/plans/plans.asp

OCFS-LDSS-4781 (Rev. 09/2015)


NOTICE OF INTENT TO CHANGE CHILD CARE BENEFITS AND FAMILY SHARE PAYMENTS NOTICE DATE:

EFFECTIVE BENEFIT CHANGE DATE


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



and assistance

1-800-342-3334

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


This agency intends to change your child care benefit. Your current benefit will end and a new benefit will begin. Your current benefit

will include services provided through

The new benefit will begin with child care services provided on through

The changes are:

Comments:


READ THE BACK OF THIS NOTICE ON HOW TO REQUEST A CONFERENCE AND/OR HEARING TO APPEAL THIS DECISION BENEFITS:

Child(ren): For this provider: For the amount of:* Full Time or Part Time:

*Payment may vary based on fluctuations in your approved activity and/or absences.










St

$


Remaining income $

Remaining income $ X family share % % = $

$ / 52 weeks = $ weekly family share.


The reason for this action is:



OCFS-LDSS-4781 (Rev.09/2015) Reverse



you want a conference, you should request one AS SOON AS POSSIBLE, because the outcome of the conference may impact your decision to request a fair hearing. If you want a fair hearing and your child care benefit to remain unchanged (aid continuing) until the fair hearing decision is issued you must request a fair hearing before the EFFECTIVE BENEFIT CHANGE DATE on the front page of this notice. A request for a conference alone will not result in your benefits being continued. At the conference, you may present information to demonstrate why you believe the agency action is not correct.






2. FAIR HEARING: You have a right to a fair hearing to appeal the determination of the local department of social services. If you

want a fair hearing, you have 60 DAYS from the NOTICE DATE, located on the front page, to make the request. If you do not want your child care benefit to change until the fair hearing decision is issued, you must request a fair hearing before the EFFECTIVE BENEFIT CHANGE DATE listed on the front page of this notice. You do not have to request a conference before requesting a fair hearing.

You may request to keep your child care benefit unchanged until a fair hearing decision has been issued. If you request your benefit not to be changed until a fair hearing decision has been issued, and you lose the fair hearing, you will have been overpaid. The local department of social services will seek to recover the overpayment from you by reducing future child care benefits, by collecting a lump sum payment or installment payments, or through legal action.





(3) Writing: Check the box and complete the information below. Mail to the New York State Office of Administrative Hearings,


(4) Faxing: Check the box and complete the information below. Fax both sides of this form to (518) 473-6735.


Select one.

Do NOT change my child care benefit until a fair hearing decision has been issued.

Change my child care benefit on the effective date listed on this notice, pending the fair hearing decision.

Name: District:


Phone Number:

If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay-stubs, receipts, child care bills, medical verification, letters, etc. that may be helpful in presenting your case



ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case

file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.




OCFS-LDSS-4781 (Rev.09/2015)

ADDENDUM TO NOTICE OF INTENT TO CHANGE CHILD CARE BENEFITS AND FAMILY SHARE PAYMENTS-FINANCIAL ELIGIBILITY CALCULATION

Effective Date:

Case Name:

Case Number:

The amount that you pay for your family share has changed from to

Below are the sources of income used to calculate your family’s income and the calculation used to determine your family share.

Please check the information below. If there is a mistake contact your caseworker listed on page one of this notice.









Family’s total monthly gross income $ X 12 months = $ Annual Income

Family’s annual gross income $

Minus 100% state income standard for a family size of $

Remaining income $

Remaining income $ X family share % % = $

$ / 52 weeks = $ weekly family share.

Family Size 100% Annual State Income Standard

1

2

3

4

5

6

7

8


*Other income not listed above and defined in New York State regulation 18 NYCRR 404.5(b)(5) are defined as but not limited to the following: net income for non-farm self-employment, i.e. gross receipts minus expenses from one’s own business, professional enterprise or partnership; or net income from farm self-employment, i.e. gross receipts minus operation expenses from the operation of a firm by a person on his own account, as owner, renter or sharecropper; or dividends, interest (on savings or bonds) income from estates or trusts, net rental income or royalties; public assistance (PA) or welfare payments include PA payments such as PA, SSI and home relief; or pensions and annuities include pensions or retirement benefits paid to a retired person or his survivors; or unemployment compensation, workers’ compensation; or alimony; or veterans’ pensions.

OCFS-LDSS-4782 (Rev. 09/2015) FRONT


NOTICE OF INTENT TO DISCONTINUE CHILD CARE BENEFITS

NOTICE DATE:

EFFECTIVE CLOSING DATE


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



and assistance

1-800-342-3334

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


This notice is to inform you that your child care benefit case will be closed on (date) / / . You are not eligible for child care

benefits for services provided after

Comments:



The reason for this action is:

Your family’s gross income exceeds 200% of the State Income Standard, which is the maximum income allowed by

New York State regulation to be eligible for child care subsidy. Your family’s monthly gross income of $

exceeds the maximum monthly income of $ for a family size of .

(Please see the attached addendum for additional information)

Due to insufficient funding, the district is closing cases at or above % of the State Income Standard.

Your family’s monthly gross income of $ exceeds the maximum monthly gross income of

$ for your family size. Also, your family does not meet the eligibility criteria for a child care

guarantee designation. (Please see the attached addendum for additional information)

You are not programmatically eligible for child care services because:

You did not provide the following documentation or the following documentation was not adequate:

Other






you want a conference, you should request one AS SOON AS POSSIBLE, because the outcome of the conference may impact your decision to request a fair hearing. If you want a fair hearing and your child care benefit to remain unchanged (aid continuing) until the fair hearing decision is issued you must request a fair hearing before the EFFECTIVE CLOSING DATE on the front page of this notice. A request for a conference alone will not result in your benefits being continued. At the conference, you may present information to demonstrate why you believe the agency action is not correct.






2. FAIR HEARING: You have a right to a fair hearing to appeal the determination of the local department of social services. If you

want a fair hearing, you have 60 DAYS from the NOTICE DATE, located on the front page, to make the request. If you do not want your child care benefit to change until the fair hearing decision is issued, you must request a fair hearing before the EFFECTIVE CLOSING DATE listed on the front page of this notice. You do not have to request a conference before requesting a fair hearing.

You may request to keep your child care benefit until a fair hearing decision has been issued. If you request your benefit to be continued until a fair hearing decision has been issued, and you lose the fair hearing, you will have been overpaid. The local department of social services will seek to recover the overpayment from you by reducing future child care benefits, by collecting a lump sum payment or installment payments, or through legal action.


(1) Calling: 1-800-342-3334. (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL)



(3) Writing: Check the box and complete the information below. Mail to the New York State Office of Administrative Hearings,




Select one.

Do NOT stop my child care benefit until a fair hearing decision has been issued.

Stop my child care benefit on the effective date listed on this notice, pending the fair hearing decision.

Name: District:


Phone Number:



Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case

file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.




OCFS-LDSS-4782 (Rev 09/2015)

ADDENDUM TO NOTICE OF INTENT TO DISCONTINUE CHILD CARE BENEFITS-FINANCIAL ELIGIBILITY CALCULATION

Effective Date:

Case Name: Case Number:

We have determined that you are no longer eligible for child care benefits. Your family’s monthly gross income is $ .

This exceeds the maximum monthly gross income standard of $ for a family size of .

Please check the information below. If there is a mistake contact your caseworker listed on page one of this notice. If there is a mistake, it could mean that the decision made about your benefits is not correct.

There is a child with special needs residing in your household. Yes No If you have a child with special needs, that needs child care, you may have received this notice in error. Contact your caseworker listed on page one of this notice to determine if your case was closed in error.








The following information is an explanation of how your eligibility for child care benefits was determined. To determine eligibility for child care benefits, your family’s monthly gross income for your family size was compared to the Social Service District’s (SSD) priority level for the monthly income standard. For a family to be eligible for child care benefits, a family must make less than the Monthly Income Standard amount listed below for their family size. Below are the Monthly Income Standards used by the district to determine your eligibility for child care benefits.

Family Size SSD’s Priority level = %

Monthly Income Standard

1

2

3

4

5

6

7

8


Your family’s monthly gross income is $ for a family size of .

This exceeds the maximum income of $ .

*Other income not listed above and defined in New York State regulation 18NYCRR 404.5(b)(5) are defined as but not limited to the following: net income for non-farm self-employment, i.e. gross receipts minus expenses from one’s own business, professional enterprise or partnership; or net income from farm self-employment, i.e. gross receipts minus operation expenses from the operation of a firm by a person on his own account, as owner, renter or sharecropper; or dividends, interest (on savings or bonds) income from estates or trusts, net rental income or royalties, public assistance (PA) or welfare payments include PA payments such as PA, SSI and home relief; or pensions and annuities include pensions or retirement benefits paid to a retired person or his survivors; or unemployment compensation, workers’ compensation; or alimony; or veterans’ pensions.

In addition to the citations listed on the attached notice refer to the district’s Child and Family Services Plan, at http://ocfs.ny.gov/main/childcare/plans/plans.asp for additional information on how the district closes cases in the event that there are insufficient funds to provide child care benefits to all eligible families and the order in which they will open new cases should funding become available.

http://ocfs.ny.gov/main/childcare/plans/plans.asp

OCFS-LDSS-4783 (Rev. 09/2015)


DELINQUENT FAMILY SHARE FOR CHILD CARE BENEFITS NOTICE DATE:


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP

OR

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

TELEPHONE NO.

This notice is to tell you that you are delinquent in making payment of your family share of $ per

. The total amount overdue is $ . If the total amount overdue

(week/month)

has not been paid, or if a satisfactory arrangement to make payment of the amount overdue has not been made by

, this agency will take action to discontinue your child care benefits.

You must pay the total amount overdue or make a satisfactory arrangement for payment of the overdue amount no later than

to avoid further action by this agency.

If you need to arrange a payment plan, contact:

Your overdue fees should be paid to:

The Law(s) and/or Regulation(s) that allow us to do this is: 18 NYCRR Section 404.6(a) and 404.6(b).

FAILURE TO PAY FAMILY SHARE OR MEET THE REQUIREMENTS OF YOUR PAYMENT PLAN WILL LEAD TO DISCONTINUANCE OF YOUR CHILD CARE BENEFITS.

OCFS-LDSS-4784 (Rev. 09/2015)

NEW YORK STATE


APPROVAL OF YOUR REDETERMINATION FOR CHILD CARE BENEFITS NOTICE DATE:

EFFECTIVE DATE


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP



and assistance

1-800-342-3334

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


Your application dated for child care benefits has been approved. You are eligible to receive child care benefits

for child care provided on through while you are .

Comments:





**Payment may vary based on fluctuations in your approved activity and/or absences. Benefits will be paid: Directly to you. Directly to your provider.

Your provider must submit a bill and attendance sheet to your local department of social services.










St

$


Remaining income $


% = $






The LAW(S) AND/OR REGLATIONS(S) that allows us to do this is:



RIGHT TO ACCEPT OR DECLINE SERVICES: Approval of your benefits does not obligate you to accept the services. You may choose to decline the services by contacting your local department of social services.


1. CONFERENCE: You have a right to a conference with your local department of social services to review the determination. If you want a conference, you should request one AS SOON AS POSSIBLE, because the outcome of the conference may impact your decision to request a fair hearing. If you want a fair hearing and your child care benefit to remain unchanged (aid continuing) until the fair hearing decision is issued you must request a fair hearing before the EFFECTIVE DATE on the front page of this notice. A request for a conference alone will not result in your benefits being continued. At the conference, you may present information to demonstrate why you believe the agency action is not correct.






2. FAIR HEARING: You have a right to a fair hearing to appeal the determination of the local department of social services. If

you want a fair hearing, you have 60 DAYS from the NOTICE DATE, located on the front page, to make the request. If you do not want your child care benefit to change until the fair hearing decision is issued, you must request a fair hearing before the EFFECTIVE DATE listed on the front page of this notice. You can request a fair hearing without requesting a conference.










Select one.



Name: District:


Phone:


LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a conference or fair hearing, how to see your file, or how to get additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice.


OCFS-LDSS-4785 (Rev. 09/2015)

NEW YORK STATE


APPROVAL OF YOUR TRANSITIONAL CHILD CARE BENEFITS

NOTICE DATE:

EFFECTIVE DATE


CASE NUMBER

CIN NUMBER



QUESTIONS OR HELP


Fair Hearing information and assistance

1-800-342-3334

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


Your transitional child care benefits have been approved. You are eligible to receive child care benefits for child care services provided

on through while you are working.

Comments:





**Payment may vary based on fluctuations in your approved activity and/or absences. Benefits will be paid: Directly to you. Directly to your provider.

Your provider must submit a bill and attendance sheet to your local department of social services.










St

$


Remaining income $


% = $






The LAW(S) AND/OR REGLATIONS(S) that allows us to do this is:


OCFS-LDSS-4785 (Rev. 09/2015) Reverse RIGHT TO ACCEPT OR DECLINE SERVICES: Approval of your benefits does not obligate you to accept the services. You may choose to decline the services by contacting your local department of social services.


1. CONFERENCE: You have a right to a conference with your local department of social services to review the determination. If you want a conference, you should request one AS SOON AS POSSIBLE, because the outcome of the conference may impact your decision to request a fair hearing. If you want a fair hearing and your child care benefit to remain unchanged (aid continuing) until the fair hearing decision is issued you must request a fair hearing before the EFFECTIVE DATE on the front page of this notice. A request for a conference alone will not result in your benefits being continued. At the conference, you may present information to demonstrate why you believe the agency action is not correct.




(3) Please keep a copy for yourself.


2. FAIR HEARING: You have a right to a fair hearing to appeal the determination of the local department of social services. If

you want a fair hearing, you have 60 DAYS from the NOTICE DATE, located on the front page, to make the request. If you do not want your child care benefit to change until the fair hearing decision is issued, you must request a fair hearing before the EFFECTIVE DATE listed on the front page of this notice. You do not have to request a conference before requesting a fair hearing.






(3) Writing: Check the box and complete the information below. Mail to the New York State Office of Administrative




Select one.



Name: District:


Phone:


LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice.


case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a conference or fair hearing, how to see your file, or how

to get additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice.


OCFS-4773 (Rev. 03/2013)


CHILD CARE ELIGIBLITY RE-DETERMINATION COMING DUE NOTICE DATE:

EFFECTIVE DATE


CASE NUMBER

CIN NUMBER


GENERAL TELEPHONE NO. FOR QUESTIONS OR HELP


Fair Hearing information and assistance

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME


In order for your child care assistance to continue, the Local Social Services District must re-determine your continued eligibility for

child care assistance. Please complete and return the enclosed application along with all the required documentation indicated below

by . If you fail to complete the application and submit the required documentation by the above date, you

will no longer be receiving child care benefits beginning on . If this happens, you will receive

the Notice of Intent to Discontinue Child Care Benefits that will advise you again when your child care will be discontinued and what

appeal rights you have to challenge this action.

We are required to re-determine your eligibility for child care assistance per 18 NYCRR 404.1(d)(2). You must submit the following documentation so that your eligibility for child care assistance can be determined.

LDSS-2921 Common Application or Local Child Care Application

The application must be completed, signed and returned to your Social Services District.

Verification of Earned Income of Household Members

If you receive child care assistance because you are working:

You must provide copies of the last 8 weeks of pay stubs, if the amount you are paid is roughly the same from paycheck to paycheck; or, if your income often notably changes from paycheck to paycheck, you must provide the last 6 months of pay stubs. If you have questions about how many pay stubs you must submit, please contact your worker at the number listed above for help.

If you are self-employed:

You must provide business records, tax records, or records and related materials concerning self-employment earnings and expenses.

If you or any other household member receives money from the following, you must provide proof of income.

Social Security Pensions/Annuities Alimony Other Income

Dividends, Interest Income Unemployment Compensation Child Support

Public Assistance Worker’s Compensation Veterans Pensions

If you receive child care assistance because you are participating in an Education / Training program you must provide: A copy of your last report card or transcript, and Documentation of the educational / training program you are attending

Verification of Residency A statement from your landlord verifying your residency or A copy of current rent receipt, lease, or mortgage statement

Other:

If you cannot obtain these items by the above date or have questions, please call your case worker at your Local Social Services

District at the number listed above for assistance.

Additional Comments:

OCFS-LDSS-7009 (Rev. 09/2015) FRONT


NOTICE OF CHILD CARE ASSISTANCE OVERPAYMENT AND REPAYMENT REQUIREMENTS

NOTICE DATE:


CASE NUMBER:

CIN NUMBER:

CASE Name (And C/O Name if Present) and ADDRESS



Fair Hearings Information and Assistance

1-800-342-3334

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

TELEPHONE NO.


READ THE BACK OF THIS NOTICE ON HOW TO REQUEST A CONFERENCE AND/OR HEARING TO APPEAL THIS DECISION SECTION I – NOTICE OF CHILD CARE ASSISTANCE OVERPAYMENT

You received more child care benefits than you should have (an overpayment) from to

. The amount of the overpayment is $ .

The reason the overpayment occurred is:

You or someone in your household failed to inform us of changes that affect your eligibility or benefit level.

We incorrectly gave you more benefits than you should have gotten due to:

Other:

Explanation and Calculation of Overpayment:

The regulations that allow us to do this are 18 NYCRR 415.4(i) and (j).

SECTION II – REPAYMENT PLAN AGREEMENT: DO NOT COMPLETE IF REQUESTING A CONFERENCE OR FAIR HEARING

If you agree that you received an overpayment, as shown in Section I, you are required to make full repayment by .

Please select a repayment option below, sign, make a copy for yourself, and return to the address at the bottom of this page.

If you are unable to repay the overpayment, want to set up another repayment agreement, or have questions please call

.

Please select one of the following repayment plan options:

Revised Family Share – Recovery will be made from my child care benefits. This option is only available if you are still receiving

child care benefits. I will pay $ per week, in addition to my current family share of $ per week.

My total family share is now $ per week. I will make this payment each week to my child care provider.

My first payment is due on . The Department of Social Services will pay the child care provider . $

per week.

Installment Payment. I will make weekly payments of $ to the Department of Social Services. I will send payment

to the address below. My first payment is due on . The Department of Social Services will pay the child

care provider $ per week.

Lump Sum Payment. I will make one payment of $ to the Department of Social Services. I will send payment

to the address below. My payment is due on

I agree to repay by this method. I understand that failure to pay the amount stated on time will result in a discontinuation of my child care benefits and/or legal action may be taken in the court to recover this overpayment.

SIGNATURE

DATE

Return this repayment plan agreement to: Return Payment to:

CLIENT/FAIR HEARING COPY

OCFS-LDSS-7009 (Rev. 09/2015) REVERSE


1. CONFERENCE: You have a right to a conference with your local department of social services to review the

determination. If you want a conference, you should request one AS SOON AS POSSIBLE, because the outcome of the conference may impact your decision to request a fair hearing. At the conference, you may present information to demonstrate why you believe the agency action is not correct.







You may request a fair hearing by: (1) Calling: 1-800-342-3334 (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL).







Name: District:


Phone Number:


LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal

Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice.


case file. If you call or write to us, we will provide you with free copies of the documents from your file, which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically

ask that they be mailed.

INFORMATION: If you want more information about your case, how to ask for a conference or fair hearing, how to see your file, or

how to get additional copies of documents, call us at the telephone numbers listed at the top of page one of this notice or write to us at the address printed at the top of page one of this notice.


OCFS-LDSS-7010 (1/2005) FRONT


NOTICE OF FRAUD DETERMINATION, DISQUALIFICATION FOR CHILD CARE BENEFITS

AND REPAYMENT PLAN

NOTICE DATE


CASE NUMBER:

CIN NUMBER:

CASE Name (And C/O Name if Present) and ADDRESS



Fair Hearings Information and Assistance 1-800-342-3334

Record Access


OFFICE NO.

UNIT NO.

WORKER NO.

UNIT OR WORKER NAME

TELEPHONE NO.

YOU HAVE THE RIGHT TO AN AGENCY CONFERENCE AND TO A FAIR HEARING TO APPEAL THIS DECISION. BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO REQUEST AN AGENCY CONFERENCE AND/OR A FAIR HEARING.

SECTION I – THIS NOTICE IS TO INFORM YOU:

1. The Department of Social Services has determined that you have fraudulently received child care benefits and you are disqualified from receiving child care benefits, AND

2. You have received an overpayment and you must repay the overpayment.

The regulation which allows us to do this is: 18 NYCRR 415.4(i).

SECTION II – FRAUD DETERMINATION

The Department’s finding of fraudulent receipt of child care benefits was based on:

Your conviction by a court of law on of fraudulently receiving child care benefits.

Your signing a voluntarily admission dated .

The fraudulent activity resulted in an overpayment of $ , occurring from to .

SECTION III – LENGTH OF DISQUALIFICATION PERIOD

As a result of the fraudulent receipt of benefits, you are disqualified from receiving child care benefits. New York State regulation, 18 NYCRR 415.4(i)(13), establishes time periods for suspension or termination of benefits depending on the number of offenses and the amount of fraudulent benefits received.

Six months, because this is your first offense.

12 months, because this is your second offense or the amount of fraudulent benefits you received was between $1,000 and

$3,900.

18 months because this is your third offense, or the amount of fraudulent benefits you received was in excess of $3,900.

Five years, because you have committed four or more previous offenses.

Other (State length of period and reason):

SECTION IV – EFFECTIVE DATE OF DISQUALIFICATION

Your disqualification will begin on and end on .

You will be subject to the above disqualification penalty if you apply for and are found eligible for child care benefits at a future date.

Your disqualification period will begin or resume once you are no longer participating in an activity required by TA.

SECTION V: REPAYMENT PLAN AGREEMENT

If you are requesting a Fair Hearing regarding this decision, you are not required to complete and sign the repayment plan at this time. However, you must complete and sign the Fair Hearing request on the reverse side of this form and return it to the address indicated.

You are required to make full repayment by . If you are unable to repay the overpayment as shown

below or you want to set up another agreement plan, or if you have any questions, please call

at , right away. Otherwise, sign this agreement, make a copy of it for yourself, and return the

agreement to the address at the bottom of this page.

Your repayment plan is shown below.

Recovery will be made from your child care benefits. To repay this debt, you must pay $ each week to your child

care provider. This is in addition to your current family share of $ per week. Effective ,

your total family share will be $ per week and the amount we pay to your provider will be reduced to $ .

To repay this debt, you must pay the Department of Social Services $ per week. Your first payment is due on

. The final payment is due on .

Send payments to:

You must continue to follow the repayment plan and/or court order that is already in effect, and is attached to this notice.

I agree to repay by this method. I understand that failure to pay the amount stated above on time will result in a discontinuation of my child care benefits and/or legal action may be taken in the court to recover this overpayment.

SIGNATURE DATE

Return this repayment plan agreement to:

CLIENT/FAIR HEARING COPY

OCFS-LDSS-7010 (1/2005) REVERSE

RIGHT TO A CONFERENCE: You may have an agency conference to review these actions. A conference is when you meet with

someone from the agency, other than the person who made the decision, to discuss your case. You may request an agency conference by calling the number on the front of this notice, in the upper right hand corner. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. Requesting an agency conference is not the same as requesting a fair hearing. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you disagree with the decision made by our agency, you may request a fair hearing. At the

hearing you will have the opportunity to present written and oral evidence to demonstrate why you think the agency’s decision is wrong and the action should not be taken. You have the right to be represented by legal counsel, a relative, friend or other person, or you may represent yourself. You have the right to bring witnesses and to question witnesses at the fair hearing. You have the right to present written and oral evidence at the hearing, and should bring any documents that may be helpful in presenting your case, such as this notice, pay stubs, receipts, child care bills, medical verification, letters, etc. There is additional information below on how to obtain access to your file and copies of documents in your file.

YOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING:

When you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or, to represent yourself.

TO REQUEST A FAIR HEARING:

Telephoning: 1 800-342-3334 (Please have this notice with you when you call). Online: Complete an online request form at: http://www.otda.state.ny.us/oah/forms.asp.

Walk In Locations: 14 Boerum Place, Brooklyn, NY OR 330 West 34th

Street, Third Floor, Manhattan, NY.

Writing: Complete the following information, sign and mail a copy of this entire notice to the New York State Office of Administrative Hearings, Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201. Please keep a copy for yourself.

Faxing: Complete the following information, sign and fax this entire notice to the New York State Office of Administrative Hearings at: 518-473-6735.

I want a fair hearing. The Agency’s action is wrong because:

I understand I may be eligible for aid continuing (current recipients only). My benefits have been stopped and I wish to have my benefits restored (aid continuing) until the hearing decision is issued.

If you request a fair hearing and aid continuing, within ten (10) days of the date of the postmark of the mailing of this notice, your child care will be reinstated and will be unchanged until the fair hearing decision is issued. However, if you lose the fair hearing, you will owe any child care that you should not have received. We are required to recover any child care overpayments. We must make a claim against you for any child care you receive that you were not entitled to, which may be collected by reduction of future child care benefits, through lump sum installment payments, or through legal action. If you want to avoid this possibility you can check the box below. You can also indicate over the telephone or in a letter that you do not want reinstatement of your child care.

I do not want my benefits continued until the hearing decision is issued.

Signature of Client: Date:

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal

Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: You have a right to look at your case file, and to receive free copies of

the documents that the agency will put into evidence and other documents necessary for you to prepare for the fair hearing. To review your file or receive copies of any documents in your file, you can call us at the Record Access telephone number listed at the top of page 1 of this notice or write us at the address printed at the top of page 1 of this notice. If you want the documents mailed to you, you must specifically ask that they be mailed. You should ask for documents ahead of time. They will be provided to you within a reasonable time before the date of the hearing.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get

copies of documents, call us at the telephone numbers listed at the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice.

http://www.otda.state.ny.us/oah/forms.asp