Attachment 1

This letter is to tell you that you and all adult members of your case and all non-complying members of your case must have a face-to-face interview to apply for public assistance in the Safety Net Assistance category.  

You all must go to the above address for your face-to-face application interview.

YOUR INTERVIEW IS ON        (DATE) AT      (TIME).

If you all do not come to your application interview, or if you do not reschedule it, we will think that you do not want Safety Net Assistance.  We will then close your Family Assistance case when you reach the 60-month time limit and we will send you a notice or notices telling you:

•	The closing date of your Family Assistance case, and
•	How the closing of your Family Assistance case will change the amount of your Food Stamp benefits.

If you are receiving Medicaid when your Family Assistance case closes, your Medicaid will continue.

If you and all adult members of your case and all non-complying members of your case cannot come to the interview, you must call the above telephone number before the interview date so we can set up another interview.

You all must apply for Safety Net Assistance if you want to receive public assistance after your Family Assistance eligibility ends.  The Welfare Reform Act of 1997 limited the amount of time an individual could receive cash public assistance to 60 months. You all must apply for SNA benefits because you, or an adult member of your case (including non-complying individuals), are able-bodied. An able-bodied person is one who is not exempt from participation in work activities under Department of Labor (DOL) regulation 1300.2. The requirement for an application for SNA is contained in 18 NYCRR 350.4 (b).

  According to our records, your State 60-month time limit count is (____) months.

If you and all adult members of your case and all non-complying members of your case apply for Safety Net Assistance, the adult(s) may be required to do applicant job search and/or may be required to be assessed for employment.  Failure to do the applicant job search and/or to be assessed WILL result in the denial of your application for Safety Net Assistance.  If your application is denied, and the adult(s) is willing to do the job search and/or the assessment at a later date, you would have to file another application for Safety Net Assistance at that time for you and your family.  This could result in a 45-day delay in benefits for your family. 

You and other adult members of your case may also be required to accept employment as part of the eligibility process.  If you do not, your Family Assistance case may be closed and your application for Safety Net Assistance may be denied.

If there have been any changes in your household’s circumstances since your last recertification or contact with this agency, you must bring proof when you report.  Some examples of a change in circumstances include people moving into or out of your household, moving, or getting or losing a job.  You must also bring with you your most recent utility bill, the name and address of your landlord and your most recent rent receipt. This is because, if you are found eligible for Safety Net Assistance when you reach your 60-month time limit for cash assistance, most of your benefits will be paid directly to vendors, such as your landlord and utility company.  A portion of your benefits may be provided in cash.

You should already have received the “Important Information about Child Care”.   If you pay for child care so you can work and have not already filled out forms to allow us to pay your provider, you can complete these forms at this interview.

If you do not want public assistance after you reach your 60-month time limit, please let us know at the interview or by contacting your worker now.  You may be eligible for transitional child care, transitional Medical Assistance and Food Stamps even if you no longer want public assistance.

If you and all other adult members of your case and all non-complying members of your case do not come to this interview and apply for Safety Net Assistance and cooperate with this process at this time and you apply for Safety Net Assistance at a later date and you are found eligible, you may have to wait 45 days from the date of your application for the benefits to begin.

									Attachment 2

Case Name: _________________________Case Number: ________________________

Date: _______________________________Worker: ____________________________

Safety Net Assistance (SNA) Application Supplement

The State Welfare Reform Act of 1997 limited the amount of time an individual could receive Family Assistance (FA) to 60 months. You and all adult members of your case (including non-complying individuals) must apply for Safety Net Assistance if you want to receive public assistance after your FA eligibility ends. You all must apply for SNA benefits because you, or an adult member of your case (including non-complying individuals), are able-bodied. An able-bodied person is one who is not exempt from participation in work activities under Department of Labor (DOL) regulation 1300.2. The requirement for an application for SNA is contained in 18 NYCRR 350.4 (b).

You, and all adult members of your case (including non-complying individuals), must complete this application and bring it and documentation of any changes to your application interview. If you do not, you and your family will not be eligible to get Safety Net Assistance when you reach the sixty-month limit on cash benefits. Please note that a new application is not required to continue to get Medicaid, Food Stamps or Child care.

18 NYCRR 370.2(c)(11) also requires as a condition of SNA eligibility that you complete and sign the two forms (Repayment Agreement (DSS-4529) and Assignment of Future Earnings – (DSS-4530)). These will be given to you to read and sign at your interview. 

Please answer the following questions:

1.	Do you want Safety Net Assistance when your sixty-month limit on cash assistance is reached?  
Yes  No 

2.	Have there been any changes in your household’s circumstances since your last recertification or contact with this agency (includes people moving in or out, moving, getting or losing a job etc.)? 

Yes  No  

 If yes, please explain the change below and provide any proof of it.

Explain Change:_________________________________________________________________________

________________________________________________________________________

You must bring with you your most recent utility bill, the name and address of your landlord and your most recent rent receipt.  This is because, if you are found eligible for Safety Net Assistance when you reach your 60-month time limit for cash assistance, most of your benefits will be paid directly to vendors, such as your landlord and utility company.  A portion of your benefits may be provided in cash.

In order to receive Safety Net Assistance, you must sign and date below.  Since this is a supplement to your application and/or your recertification applications where you checked the box “cash assistance”, all the certifications, authorizations, consents, releases, assignments and other information you read, agreed to and signed to on your original application forms remain in effect.
   
In signing this application, I swear and affirm under penalty of perjury that all the information I have provided is accurate. I understand that if any of my benefits are changed as a result of this information I will receive notice before the change is made.

Applicant Signature: _____________________________Date: ___________________

Spouse Signature: _______________________________Date: ___________________

Other Adults:	___________________________________Date: ___________________

		___________________________________Date: ___________________

		___________________________________Date: ___________________