Form W-137b
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Form W-137B (page 1) (LDSS-4002) LLF Rev. 6/5/09
Date: Case number: Case Name: Center: Worker Telephone No.: FH&C Telephone No.:
Action Taken on Your Request for Emergency Assistance or Additional Alowance (For Participants Only) The Agency's decision(s) regarding your benefit program(s) is/are explained below, next to the checked box(es) �. 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
, you requested
� Emergency Assistance
þ Additional Allowance for:
(Date)
Security Deposit, Rent, Brokers' Fee Furniture Allowace
þ Your Request for additional allowances þ One payment in the amount of $ Method of payment: o Broker's or finder's fee/voucher
has been accepted. You will receive: . Period covered, if applicable:
þ Check to be picked up by you at
o Check mailed to your home
your Job Center oAs an addition to your regular
o Security deposit agreement
o Direct vendor check
public grant, which can be obtained through the EBT system oOther action: oYou will receive a second notice informing you as to how your ongoing benefits will be affected.
.
Form W-137B (page 1) (LDSS-4002) LLF Rev. 6/5/09
o On you were referred to the Burial Claims Unit at 25 Chapel Street, Room 606, Brooklyn, NY 11201, (718) 473-8310, to apply for a burial allowance.
o Your Request for
has been denied because:
The law(s) and/or regulation(s) that allow(s) us to do this is/are 18 NYCRR (please see the section numbers below):
o Addition To Household § 352.30
o Broker's or Finder's Fee/Voucher § 352.6(a)
o Payment to Maintain or Restore Utility Services § 352.5
o Repair of Essential Household Items § 352.7(b)
o Work Activity Related Supportive Services § 385.4
o Additional Allowance
o Back Mortgage and/or
for Fuel § 352.5
Taxes § 352.7(g)
o Catastrophic Loss (replacement of clothing and furniture lost in fire, flood or other disaster) § 352.7(a)
o Furniture and Other Household Items § 352.7(a)
o Back Rent § 352.7(g) o Moving Expenses § 352.6(a)
o Pregnancy Allowance § 352.7(k)
o Property Repairs § 352.4(d), § 352.6(e)
o Rent Security Deposit/ Letter of Guarantee § 352.6(a)
o Restaurant Allowance § 352.7(c )
o Semimonthly Fuel for Heating Allowance § 352.5(b)
o Storage of Furniture and Personal Belongings § 352.6(f)
Form W-163D Rev. 2/14/06
Date: Case number: Case Name: Center:
Acknowledgement of Assignment of Security Deposit (Mail two copies to landlord and attachone copy of form W-163.)
:
Dear: Landlord's Name Attached is an Assignment of Security Deposit form (W-163) from:
, who Resides in your building at (Name of Tenant) (Address)
apartment number
in the amount of $
.
When tenancy is terminated, the security deposit must be returned to the Family Independence Administration in the Human Resources Administration. Unless otherwise notified in writing by the New York City Department of Social Services, said security deposit shall be returned by check, made payable to the commissioner of the NYC Department of Social Services, and mailed to: New York City Department of Social Services Division of Accounts Receivable & Billing 180 Water Street, Room 912 New York, NY 10038 The attached copy of the notarized W-163 is for your files.
A.
Please indicate the name and address of the bank where the security deposit will be held in trust:
(Name of Bank) (Address of Bank)
Please acknowledge your receipt of the Assignment of Security Deposit form by signing below and returning this form to us at the address above. Please keep a copy for your files. I, (Landlord)
acknowledge receipt of Assignment of Security Deposit form. B.
You are required on an annual basis to remit all interest on the deposit to: New York City Department of Social Services Investigation, Revenue and Enforcement Administration (IREA) P.O. Box 5915 New York, NY 10087-5915
JOS/Worker's Signature Landlord's Signature
Date Date (Scan one copy of this form and the W-163 into the electronic file.)
Date: Case number: Case Name: Center: Worker Telephone No.: FH&C Telephone No.:
Action Taken on Your Request for Emergency Assistance or Additional Alowance (For Participants Only) The Agency's decision(s) regarding your benefit program(s) is/are explained below, next to the checked box(es) �. 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
, you requested
� Emergency Assistance
þ Additional Allowance for:
(Date)
Security Deposit, Rent, Brokers' Fee Furniture Allowace
þ Your Request for additional allowances þ One payment in the amount of $ Method of payment: o Broker's or finder's fee/voucher
has been accepted. You will receive: . Period covered, if applicable:
þ Check to be picked up by you at
o Check mailed to your home
your Job Center oAs an addition to your regular
o Security deposit agreement
o Direct vendor check
public grant, which can be obtained through the EBT system oOther action: oYou will receive a second notice informing you as to how your ongoing benefits will be affected.
.
Form W-137B (page 1) (LDSS-4002) LLF Rev. 6/5/09
o On you were referred to the Burial Claims Unit at 25 Chapel Street, Room 606, Brooklyn, NY 11201, (718) 473-8310, to apply for a burial allowance.
o Your Request for
has been denied because:
The law(s) and/or regulation(s) that allow(s) us to do this is/are 18 NYCRR (please see the section numbers below):
o Addition To Household § 352.30
o Broker's or Finder's Fee/Voucher § 352.6(a)
o Payment to Maintain or Restore Utility Services § 352.5
o Repair of Essential Household Items § 352.7(b)
o Work Activity Related Supportive Services § 385.4
o Additional Allowance
o Back Mortgage and/or
for Fuel § 352.5
Taxes § 352.7(g)
o Catastrophic Loss (replacement of clothing and furniture lost in fire, flood or other disaster) § 352.7(a)
o Furniture and Other Household Items § 352.7(a)
o Back Rent § 352.7(g) o Moving Expenses § 352.6(a)
o Pregnancy Allowance § 352.7(k)
o Property Repairs § 352.4(d), § 352.6(e)
o Rent Security Deposit/ Letter of Guarantee § 352.6(a)
o Restaurant Allowance § 352.7(c )
o Semimonthly Fuel for Heating Allowance § 352.5(b)
o Storage of Furniture and Personal Belongings § 352.6(f)
Form W-163D Rev. 2/14/06
Date: Case number: Case Name: Center:
Acknowledgement of Assignment of Security Deposit (Mail two copies to landlord and attachone copy of form W-163.)
:
Dear: Landlord's Name Attached is an Assignment of Security Deposit form (W-163) from:
, who Resides in your building at (Name of Tenant) (Address)
apartment number
in the amount of $
.
When tenancy is terminated, the security deposit must be returned to the Family Independence Administration in the Human Resources Administration. Unless otherwise notified in writing by the New York City Department of Social Services, said security deposit shall be returned by check, made payable to the commissioner of the NYC Department of Social Services, and mailed to: New York City Department of Social Services Division of Accounts Receivable & Billing 180 Water Street, Room 912 New York, NY 10038 The attached copy of the notarized W-163 is for your files.
A.
Please indicate the name and address of the bank where the security deposit will be held in trust:
(Name of Bank) (Address of Bank)
Please acknowledge your receipt of the Assignment of Security Deposit form by signing below and returning this form to us at the address above. Please keep a copy for your files. I, (Landlord)
acknowledge receipt of Assignment of Security Deposit form. B.
You are required on an annual basis to remit all interest on the deposit to: New York City Department of Social Services Investigation, Revenue and Enforcement Administration (IREA) P.O. Box 5915 New York, NY 10087-5915
JOS/Worker's Signature Landlord's Signature
Date Date (Scan one copy of this form and the W-163 into the electronic file.)
