Article Guide
The Snap Periodic Report NYC form, known as LDSS-4310, is an essential document for individuals and families participating in the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as the Food Stamp Program. This form plays a crucial role in ensuring that you continue to receive your benefits without interruption. It requires you to provide updated information about your household’s income and any significant changes that may have occurred since your last interaction with your eligibility worker. Completing this report accurately and on time is vital, as it directly affects your Child Assistance (CAP), Child Care, and SNAP benefits. The form includes specific sections that guide you in reporting income from various sources, such as employment or social security, and prompts you to disclose any changes in your household composition or financial situation. It is important to follow all instructions carefully and return the completed form by the specified due date to avoid any potential disruptions in your assistance. Remember, if you fail to submit the report on time, your benefits may be reduced or stopped altogether. However, it is reassuring to note that your Medicaid coverage will remain unaffected by this process. Engaging with this form may seem daunting, but it is a necessary step to ensure you and your family continue to receive the support you need.
Preview - Snap Periodic Report Nyc Form
Periodic Report
Supplemental Nutrition Assistance Program (SNAP) is the new name for the Food Stamp Program.
You must fill out this Report and return it to the address listed on the back by
______________ 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.
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 SNAP Benefits being discontinued.
CASE NAME |
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CASE NUMBER |
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OFFICE |
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UNIT |
WORKER |
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We must get your completed Report by |
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If you have any questions on how to fill out |
__________________ |
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this Report, call |
:(___) ________________ |
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the completed Report by this date, your Child Assistance (CAP), Child Care |
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and/or SNAP Benefits will stop. Failure to return this report will not affect your |
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Medicaid coverage. |
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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 SNAP Benefits.
2.You must complete and sign this Report and return it to the address on the back of this report by __________________, or your Child Assistance (CAP), Child Care or SNAP 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 SNAP, 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.
household does not include a child under 18 years of age. (Write who and the months not meeting the requirement below.)
An able-bodied adult in your household did not work/participate in a work activity for at least 80 hours in each month and your SNAP
SECTION 1: Please list ALL income for EACH household member. If you are only receiving SNAP benefits, you only have to list earnings here for each household member who works.
(Examples of income include earnings from a job, Unemployment Insurance, Social Security Benefits, Supplemental Security Income [SSI])
Who
Name of Employer or Other
Source of Income
How Often?
(Daily, Weekly,
Total # of Hours
Worked Per Week
Send in proof of all income that any household member got during the entire month of _______________________.
Since you participate in the Child Assistance Program (CAP), send proof of earnings, other income, and child care costs for _________________________, __________________________, __________________________.
SECTION 2: Have there been any other changes (read boxes below) since your last Report, or do you expect any changes?
□ 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 (cost you pay not child care subsidy) are new or changed or child care provider changed (Write new amount and who
provides the child care.)
□ Someone is pregnant (Write who and expected delivery date, if known.) □ Death or Birth of someone in the household (Write who and when.)
□ Change in legally obligated child support paid by a member of your household (Write who in your household pays the support.) □ Other changes that may affect benefits (Write who, what, and when change occurred and give proof, if possible.)
Write the details of your change(s) here, and if you have proof send it in:
CERTIFICATION: I understand that the information I provide on this report may result in changes in my assistance, including reducing the amount of my Temporary Assistance Benefits, SNAP Benefits, Child Care Benefits or closing my case. I am aware that Federal and State Law provide for fine and/or imprisonment of any person who fraudulently attempts to receive, or fraudulently receives Temporary Assistance, Medicaid, Child Care or SNAP Benefits to which the person is not entitled. Information reported on this form may affect my eligibility for Medicaid.
I understand that I must contact my worker to report any changes that occur for my Temporary Assistance and Medicaid case within 10 days.
I understand that I must contact my worker immediately if any changes occur that affects my child care. I also understand that if I use a child care provider who is not licensed or registered, my provider must meet certain requirements in order to be paid.
For my SNAP case, I must report changes on the Periodic Report and at Recertification, whichever occurs first. I may also report changes at any other time.
IMPORTANT- YOU MUST SIGN AND RETURN THIS FORM. IF YOU CHECKED “YES” TO ANY CHANGES IN SECTION 2, MAKE SURE YOU CHECKED (√) THE BOX(ES) AND GAVE MORE DETAIL. IF THIS REPORT IS NOT COMPLETE, WE WILL SEND YOU A DISCONTINUANCE NOTICE.
Your Signature:
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 |
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Form Characteristics
| Fact Name | Details |
|---|---|
| Form Title | LDSS-4310 (Rev. 1/13) Periodic Report for the Supplemental Nutrition Assistance Program (SNAP). |
| Submission Deadline | The completed report must be returned by the specified due date to continue receiving benefits. |
| Importance of Completion | Failure to complete and return the report may lead to the discontinuation of Child Assistance, Child Care, and/or SNAP benefits. |
| Reporting Changes | Participants must report any changes in their household or income within ten days after the end of the month if income exceeds the given limit. |
| Certification Requirement | Participants must sign the report, acknowledging that providing false information can lead to legal consequences. |
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