W-137B (page 1 of 6) (LDSS-4002) 03/16/2020 LLF

CA4 Bushwick Job Center

2 George St
Date: 03/19/2024
Brooklyn NY 11206 Case Number : 00003660070I
Case Name : SMITH SCEIRA
Sceira Smith
Center: Bushwick Job Center
1266 SUTTER AVE
Caseload : WMCJT
Apt 4F
Worker Telephone No.: () -
BROOKLYN NY 112083871
FH&C Telephone No.: () -

Action Taken on Your Request for Emergency Assistance,

Additional Allowances, or to Add a Person to the Cash Assistance Case
(For Participants Only)
The Agency's decision(s) regarding your benefit program(s) is/are explained below, next to the
checked box(es) ý.
This Notice applies only to your request for an additional allowance to meet a special need, a
change in grant, or an application for emergency assistance. If your request for additional
assistance is denied, your ongoing Cash Assistance case will not be affected.

On 01/25/2024 , you requested b

c
d
e
f
g Emergency Assistance
(Date) b
c
d
e
f
g Additional allowance for:
Replacement of Clothing lost as a result of a disaster such as homelessness or fire

c
d
e
f
g Your request for has been accepted. You will receive:
c One payment in the amount of $
d
e
f
g .
Period covered, if applicable: .

How we will pay:

c
d
e
f
g Broker's or finder's c
d
e
f
g You must pick up check at your c
d
e
f
g Check mailed to your
fee/voucher paid to Job Center home
broker/finder

c
d
e
f
g We will add it to your c
d
e
f
g Security deposit/agreement/ c
d
e
f
g Check sent directly to
regular Cash Assistance voucher paid/provided landlord/vendor
grant which you can get to landlord
through the EBT system

c
d
e
f
g Other action:

b
c
d
e
f
g You will receive a second notice informing you as to how your ongoing benefits will be
affected.
(Turn page)
W-137B (page 2 of 6) (LDSS-4002) 03/16/2020 Human Resources Administration
LLF Family Independence Administration

c On
d
e
f
g , you were referred to the Office of Burial Services at 33-28 Northern
Boulevard, 3rd Floor, Long Island City, NY 11101, (718) 473-8310, to apply for a burial allowance.

b
c
d
e
f
g Your request for Replacement of Clothing lost as a result of a disas... has been denied because:

Insufficient document

The law(s) and/or regulation(s) that allow(s) us to do this is/are 18 NYCRR (please see the
section numbers below):
c Addition to
d
e
f
g c Additional Allowance
d
e
f
g c Back Mortgage
d
e
f
g c Back Rent
d
e
f
g
Household for Fuel and/or Taxes § 352.7 (g)
§ 352.30 § 352.5 § 352.7 (g)

c
d
e
f
g Broker's or Finder's b
c
d
e
f
g Catastrophic Loss c
d
e
f
g Furniture and Other c
d
e
f
g Moving
Fee/Voucher (replacement of Household Items Expenses
§ 352.6(a) clothing and furniture § 352.7(a) § 352.6(a)
lost in fire, flood or
other disaster)
§ 352.7(d)

c
d
e
f
g Repair of c
d
e
f
g Pregnancy c
d
e
f
g Property Repairs c
d
e
f
g Rent Security
Essential Allowance § 352.4(d), Deposit/
Household Items § 352.7(k) § 352.6(e) Letter of
§ 352.7(b) Guarantee
§ 352.6(a)

c
d
e
f
g Work Activity c
d
e
f
g Restaurant Allowance c
d
e
f
g Semimonthly c
d
e
f
g Storage of
Related Supportive § 352.7(c) Fuel for Furniture and
Services Heating Allowance Personal
§ 385.4 § 352.5(b) Belongings
§ 352.6(f)

g Other
c
d
e
f (specify):
03/19/2024
JOS/Worker's Name Date
03/19/2024
Supervisor's Name Date

(Turn page)
W-137B (page 3 of 6) (LDSS-4002) 03/16/2020 Human Resources Administration
Family Independence Administration
LLF

Do you have a medical or mental health condition or disability? Does this condition
make it hard for you to understand this notice or to do what this notice is asking? Does this
condition make it hard for you to get other services at HRA? We can help you. Call us at 212-
331-4640. You can also ask for help when you visit an HRA office. You have a right to ask for
this kind of help under the law.

YOU HAVE THE RIGHT TO APPEAL THIS DECISION.

BE SURE TO READ THE CONFERENCE AND FAIR HEARING INFORMATION
SECTION OF THIS NOTICE FOR HOW TO APPEAL THIS DECISION.

(Turn page)
W-137B (page 4 of 6) (LDSS-4002) 03/16/2020 Human Resources Administration
Family Independence Administration
LLF

Conference and Fair Hearing Information

CONFERENCE
If you think our decision is wrong, or if you do not understand our decision, please call us to set up
a conference (a conference is an informal meeting with us). To do this, call the Fair Hearing and
Conference (FH&C) unit phone number on page 1 of this notice or write to us at the address on
page 1 of this notice. Sometimes this is the fastest way to solve a problem you may have. We
encourage you to do this even if you have asked for a Fair Hearing. If you ask for a conference, you
are still entitled to a Fair Hearing.
STATE FAIR HEARING
Deadline: If you want the State to review our decision, you must ask for a Fair Hearing within sixty
(60) days from the date of the notice for Cash Assistance, medical assistance, or social services
issues; and you must ask within ninety (90) days for Supplemental Nutrition Assistance Program
(SNAP) issues.
If you cannot reach the New York State Office of Temporary and Disability Assistance by phone, by
fax, in person or online, please write to ask for a Fair Hearing before the deadline.
How to Ask for a Fair Hearing: If you believe the decision(s) we are making is/are wrong, you
may request a State Fair Hearing by telephone, in writing, fax, in person or online.
(1) TELEPHONE: Call (800) 342-3334. (Please have this notice in hand when you call.)
(2) WRITE: Send a copy (and keep a copy for yourself) of this entire notice, with the "Fair
Hearing Request" section completed, to:
Office of Administrative Hearings
New York State Office of Temporary and Disability Assistance
P.O. Box 1930
Albany, NY 12201

(3) FAX: Fax a copy of this entire notice, with the "Fair Hearing Request" section
completed, to: (518) 473-6735.
(4) IN PERSON: Bring a copy of this entire notice, with the "Fair Hearing Request" section
completed, to the Office of Administrative Hearings, New York State Office
of Temporary and Disability Assistance at: 14 Boerum Place, Brooklyn
NY 11201
(5) ONLINE: Complete an online request form at:
http://www.otda.state.ny.us/oah/forms.asp

(Turn page)
W-137B (page 5 of 6) (LDSS-4002) 03/16/2020 Human Resources Administration
Family Independence Administration
LLF

What to Expect at a Fair Hearing: The State will send you a notice that tells you when and
where the Fair Hearing will be held. At the hearing, you will have a chance to explain why you
think our decision is wrong. To help explain your case, you can bring a lawyer and/or witnesses
such as a relative or a friend to the hearing, and/or give the Hearing Officer any written
documentation related to your case such as: pay stubs, leases, receipts, bills and/or doctor's
statements, etc. If you cannot come yourself, you can send someone to represent you. If you are
sending someone who is not a lawyer to the hearing instead of you, you must give that person a
letter to show the Hearing Officer that you want that person to represent you. At the hearing, you,
your lawyer or your representative can also ask questions of witnesses whom we bring, or you
bring, to explain the case.

If you have a disability, and cannot travel, you may appear through a representative such as
a friend, relative or lawyer. If your representative is not a lawyer, or an employee of a lawyer, your
representative must bring the hearing officer a written letter, signed.

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 the Yellow Pages
under "Lawyers."
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 files. If you call, write, or fax us, we will send you free
copies of the documents from your files, which we will give to the Hearing Officer at the Fair
Hearing. Also, if you call, write or fax us, we will send you free copies of specific documents from
your files which you think you may need to prepare for your Fair Hearing. To ask for documents or
to find out how to look at your file, call (718) 722-5012, fax (718) 722-5018 or write to HRA
Division of Fair Hearing, 14 Boerum Place, Brooklyn, New York 11201. 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.
AVAILABILITY OF POLICY MATERIALS: The Office of Temporary and Disability Assistance
(OTDA) policy issuances and HRA policy issuances and manuals are available to you or your
representative to determine whether a fair hearing should be requested or to prepare for a fair
hearing. OTDA policy issuances and manuals are posted on the OTDA website at
http://www.otda.ny.gov/legal. In addition, upon request to HRA, specific OTDA and HRA
policy issuances and manuals are also available to explain how the agency reached its
determination. To request policy issuances and manuals, call (718) 722-5012, or fax (718) 722-
5018, or email [email protected] or write to HRA Division of Fair Hearing, 14 Boerum
Place, Brooklyn, NY 11201.

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 additional copies of documents, call or write to us at the phone
number/address listed on page 1 of this notice.

(Turn page)
W-137B (page 6 of 6) (LDSS-4002) 03/16/2020 Human Resources Administration
Family Independence Administration
LLF

FAIR HEARING REQUEST

c
d
e
f
g I want a Fair Hearing. The Agency's decision is wrong because:

Print Name: Case Number:

Name M.I. Last Name

Address:
Telephone:
City: State: Zip Code:

Signature: Date: