LDSS-4921	(1/08)				          	                        NYS OTDA	

WORKING FAMILIES FOOD STAMP INITIATIVE SCREENING SHEET

Answer the following 2 Questions below.

Answering “YES” to either of the questions below identifies the applicant household as presumptively qualifying for the Working Families Food Stamp Initiative.  No additional verification is necessary beyond the information on a signed application to establish presumptive eligibility. 

Presumptively qualifying for the Working Families Food Stamp Initiative does not mean that a household is eligible for Food Stamp Benefits.  

QUESTION 1

Is any adult (18 years of age or older) member of your household either working 30 or more hours per week or earning $175.50 or more per week? 

YES ____        NO ____

(If you answered “YES” to QUESTION 1, then you do not have to answer QUESTION 2.)

QUESTION 2

Are any two (2) adult members of your household each either working 20 or more hours per week or earning $117 or more per week?

Yes ____        No ____

For local district workers Only	
Case Name:	Case Number:	Date App Filed:	
Screened By: 	Date Screened: 	
	
Eligibility Interview:	
By Telephone	
In-Person	
Other	

   Qualified for WFFSI					

   Not Qualified for WFFSI