NEW YORK STATE

George E. Pataki OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE Robert Doar

Governor 40 NORTH PEARL STREET Commissioner
ALBANY, NY 12243-0001

Informational Letter
Section 1
Transmittal: 06-INF-09
To: Local District Commissioners
Issuing Division of Employment and Transitional Supports
Division/Office:
Date:March 3, 2006
Subject: Revisions for the LDSS-3151: Food Stamp Change Report Form (Rev.1/06)
Suggested Temporary Assistance Staff
Distribution: Food Stamp Benefits Staff
Medicaid Directors
CAP Coordinators
Employment Coordinators
WMS Coordinators
Staff Development Coordinators
Contact Forms Questions: Bob Gullie 1-800-343-8859 Extension 6-1095
Person(s): Program Questions:
Food Stamp Bureau - (518) 473-1469
Temporary Assistance Bureau - (518) 474-9344
HEAP Bureau - (518) 473-0332
Metro Region - (212) 961-8207
WMS Questions: (518) 474-8749
Attachments: LDSS-3151 (1/06)
Attachment Available On –
Line:

Filing References

Previous Releases Dept. Regs. Soc. Serv. Manual Ref. Misc. Ref.
ADMs/INFs Cancelled Law & Other
Legal Ref.
04 ADM-02 387.17 (e) 7CFR 273.12
02 ADM-7 (a)
01 ADM-9
03OMM/ADM
-2
04 INF-15
03 INF-33
03 INF-10
02 INF-8
03 INF-2
Section 2
I. Purpose
The purpose of this release is to introduce the revised (1/06) LDSS-3151: “Food Stamp Change
Report Form” (copy attached). This mandated form is used by local districts to solicit information
from Food Stamp benefits recipients on changes in household circumstances.

The primary reason for this revision is to update the change reporting requirements for Food Stamp
Benefits households who are subject to change reporting (non-six-month reporting households).
The requirement has been modified to allow non-six-month reporting households to report the
changes within ten (10) days after the calendar month in which the change occurred.

II. Forms Revisions

The following are the changes to the 2/04 “Food Stamp Change Report Form” which are
incorporated into the 1/06 version:
A. General - The revision date was changed on every page to 1/06.
B. Page 1

1. The reference to “five months” in question #3 on Page 1 was changed to “three months.”

2. The instruction, if you answer “Yes” to question #4 on Page 1, was changed to read:
YES – Go to “Six-Month Reporting” on page 2 (Skip questions 5 through 8)

3. The reference to “disabled” in question #5 on Page 1 was changed to read:

“permanently disabled”

C. Page 2

1. The first sentence in Section 3 on Page 2 was changed to read:

If anyone in your food stamp household is an Able-Bodied Adult Without Dependents
(“ABAWD”), you MUST tell us if their work hours go below 80 hours a month within 10
days after the end of that month.

2. The introductory statement under “CHANGE REPORTING RULES” in Section 3 on

Page 2 was changed to read:
As a food stamp household under the “Change Reporting” rules, you MUST report the
following changes within 10 days after the end of the month in which the change happened:

3. The 9th bullet under the “CHANGE REPORTING RULES” on Page 2 was changed to
read:
Increases in your household’s cash, stocks, bonds, money in the bank or savings
institution if the total cash and savings of all household members now amounts to more
than $2000 for a household without an elderly or permanently disabled household member
or $3000 for a household with an elderly or permanently disabled household member.
OTDA 06-INF-09 2
(Rev. 3/2006)
 4. The 10th bullet under the “CHANGE REPORTING RULES” on Page 2 was changed to
read:
If anyone in your food stamp household is an Able-Bodied Adult Without Dependents
(“ABAWD”), you MUST tell us if their work hours go below 80 hours a month within 10
days after the end of that month.

III. Forms Ordering Information:

• Supplies of the 1/06 version of the LDSS-3151 are expected to be delivered to the Upstate (Albany)
and the HRA (New York City) warehouses in early May 2006. All existing copies of the old (2/04)
versions of the LDSS-3151 must be destroyed upon receipt of the revised, 1/06 versions.
Local districts will automatically receive supplies of the English 1/06 version. The “Other than
English” versions of the LDSS-3151 will follow. When the Spanish version (LDSS-3151-SP) is
printed, only NYC will automatically receive supplies. Other districts must order the LDSS-3151-SP
using the procedure described below.

• Any requests for printed copies of the 1/06 versions of the LDSS-3151 and LDSS-3151-SP
should be submitted on OTDA-876 “Request For Forms or Publications,” and should be sent to:

Office of Temporary and Disability Assistance

BMS Document Services and Operational Support
P.O. Box 1990
Albany, New York 12201

Questions concerning ordering forms should be directed to BMS Document Services at 1-800-343-
8859, ext. 4-9522.

• Documents also may be ordered through Outlook. To order the forms you must obtain an OTDA-
876 electronically by going to the OTDA Intranet Website at http://otda.state.nyenet/ then to
Division of Program Support & Quality Improvement page, then to PSQI E-Forms page to Bureau
of Management Services section (this section contains the electronic OTDA-876).

• For those who do not have Outlook but who have Internet access for sending and receiving email,
the Internet email address is: gg7359@otda.state.ny.us. For a complete list of available forms,
please refer to OTDA Intranet site: http://sdssnet5/otda/ldss_eforms.

Issued By _________________________________________________
Name: Russell Sykes
Title: Deputy Commissioner
Division/Office: Division of Employment and Transitional Supports

OTDA 06-INF-09 3
(Rev. 3/2006)
LDSS-3151 (Rev. 1/06) PAGE 1
NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE CASE NUMBER
FOOD STAMP CHANGE REPORT FORM
(Please Print Clearly)

YOU MUST REPORT ANY CHANGES IN YOUR CIRCUMSTANCES DATE: _________________

ACCORDING TO THE RULES LISTED BELOW.
COMPLETE THIS FORM AND MAIL TO:
LOCAL DISTRICT NAME, ADDRESS AND TELEPHONE NUMBER:
TO:
ADDRESS:

YOUR RESPONSIBILITY TO REPORT CHANGES

Please read the questions and rules carefully. If you fail to report any changes that you are
required to report under the rules, we may have to establish a claim for overpayment of food
stamp benefits and collect the amount of the overpayment from you.

The changes that you MUST report are explained below. You may still voluntarily report any change
about your food stamp household and, if this change will increase your benefit level and you verify this
change, we will increase your benefit.

ARE YOU A “SIX-MONTH REPORTER” OR A “CHANGE REPORTER”? YOU MAY ANSWER

THESE QUESTIONS TO FIND OUT WHETHER YOU ARE A “SIX-MONTH REPORTER” OR A
“CHANGE REPORTER”.

1. Do you receive transitional food stamp

benefits (TBA)?
… YES – Go To “TBA” on page 3 … NO – Go To Question #2, below
(Skip questions 2 through 8)

2. Do you receive New York State Nutrition

Improvement Project (NYSNIP)
… YES – Go To “NYSNIP” on page 3 … NO – Go To Question #3, below
(Skip questions 3 through 8)
benefits?

3. Are you certified for food stamp benefits

for three months or less at a time?
… YES –Go To “Change Reporting” on … NO – Go To Question #4, below
page 2 (Skip questions 4 through 8)

4. Does anyone in your household have

earned income that is being counted in
… YES –Go To “Six-Month Reporting” … NO – Go To Question #5, below
on page 2 (Skip questions 5 through
your food stamp benefit amount? 8)

5. Are all of the adults (18 or older) in your

household either permanently disabled
… YES –Go To “Change Reporting” on … NO – Go To Question #6, below
page 2 (Skip questions 6 through 8)
or 60 or older?
6. Does your household receive $0 income
(including $0 Temporary Assistance)
… YES –Go To “Change Reporting” on … NO – Go To Question #7, below
page 2 (Skip questions 7 and 8)

7. Are you without shelter (undomiciled) or

a migrant/seasonal farmworker?
… YES – Go To “Change Reporting” … NO – Go To #8, below
on page 2 (Skip question 8)

8. You answered “NO” to all 7 questions

above
… Go To “Six-Month Reporting” on the
top of page 2
PAGE 2 LDSS-3151 (Rev. 1/06)

SIX-MONTH REPORTING RULES: As a food stamp household under the “Six-Month Reporting” rules, you are only required to
report changes at the time of your next recertification, except for the following three situations:
1. If your household’s gross monthly income exceeds 130% of the poverty level, you MUST report this monthly amount to
your social services district by telephone, in writing, or in person within 10 days after the end of the calendar month in
which you exceed the 130% level. Gross income is the amount of income before taxes and other deductions are taken out, not
the amount you receive when you cash your check. We must use the gross income in figuring your eligibility for food stamp
benefits. Your worker will explain what 130% of the poverty level means for a family of your size. Any other kind of income that
you receive besides earnings must be added to your gross earned income to know if you are over 130% of the poverty level.
Examples of other sources of income that count include child support you receive, Unemployment Insurance, Temporary
Assistance (TA) payments, Workers Compensation, Social Security Benefits, Supplemental Security Income (SSI) and private
disability payments.
If you fail to report that your gross income is above 130% of the poverty level in any calendar month, all benefits received after
that month may be considered an overpayment. This is true even if your gross income falls below the 130% poverty level in a
future month.

2. If your household’s certification period is longer than 6 months: At a six-month checkpoint into your certification period, you
will receive a report form that you MUST return within ten days after you receive the form. If your household has any of the
changes listed below, you MUST report them on the report form that is sent to you at the six-month checkpoint.
List of Changes you must report at the six-month checkpoint:
• Changes in any source of income for anyone in your household
• Changes in your household’s total earned income when it goes up or down by more than $100 a month
• Changes in your household’s total unearned income from a public source such as Social Security Benefits or
Unemployment Insurance Benefits when it goes up or down by more than $50 a month
• Changes in your household’s total unearned income from a private source such as Child Support Payments or Private
Disability Insurance when it goes up or down by more than $100 a month
• Changes in the amount of court ordered child support you pay to a child outside of your food stamp household
• Changes in who lives with you
• If you move, your new address and your new rent or mortgage costs, heat costs and utility costs
• A new or different car, or other vehicle
• Increases in your household’s cash, stocks, bonds, money in the bank or savings institution if the total cash and
savings of all household members now amounts to more than $2000 (more than $3000 if anyone in your household is
disabled or 60 years old or older)
• Any changes in your household that would result in a penalty as described on page 6

3. If anyone in your food stamp household is an Able-Bodied Adult Without Dependents (“ABAWD”), you MUST tell us if their
work hours go below 80 hours a month within 10 days after the end of that month.

CHANGE REPORTING RULES:

As a food stamp household under the “Change Reporting” rules, you MUST report the following changes within 10 days after the end
of the month in which the change happened:
• Changes in any source of income for anyone in your household
• Changes in your household’s total earned income when it goes up or down by more than $100 a month
• Changes in your household’s total unearned income from a public source such as Social Security Benefits or
Unemployment Insurance Benefits when it goes up or down by more than $50 a month
• Changes in your household’s total unearned income from a private source such as Child Support Payments or Private
Disability Insurance when it goes up or down by more than $100 a month
• Changes in the amount of court ordered child support you pay to a child outside of your food stamp household
• Changes in who lives with you
• If you move, your new address and your new rent or mortgage costs, heat costs and utility costs
• A new or different car, or other vehicle
• Increases in your household’s cash, stocks, bonds, money in the bank or savings institution if the total cash and savings
of all household members now amounts to more than $2000 for a household without an elderly or permanently disabled
household member or $3000 for a household with an elderly or permanently disabled household member.
• If anyone in your food stamp household is an Able-Bodied Adult Without Dependents (“ABAWD”), you must tell us if their
work hours go below 80 hours a month within 10 days after the end of that month
• Any changes in your household that would result in a penalty as described on page 6
LDSS-3151 (Rev. 1/06) PAGE 3

TBA CHANGE REPORTING for household in receipt of transitional benefits:

• Transitional food stamp benefits can continue for up to five months after your Temporary Assistance case closes.
• You are not required to report changes during the transition period. If you have changes that may increase your benefits you
can contact your worker to file an early recertification application at any time during your transitional period to receive the
increase. The increase cannot be done until a signed recertification application is filed, and the entire recertification process
is completed.
• You must recertify near the end of your transitional period to see if you can continue to receive food stamp benefits after
your transitional period ends. We will send you a notice reminding you of this recertification requirement. If you do not
recertify, we will not send you any other notice and must close your food stamp case.

NYSNIP CHANGE REPORTING for participants in NYSNIP:

• You will receive a contact letter 24 months after you begin participation in NYSNIP that you must complete and return.
• You are not required to report changes during your certification period other than the 24-month contact letter. You may
voluntarily report increases in your medical expenses, rent or utility costs, or decreases in your income. If you report and
verify these changes, you may be eligible for more food stamp benefits. You may also report your new address if you
move, so that you can continue to receive any notices we send to you.

Medical Expenses: You are not required to report changes in your medical expenses during your certification period. However,
you may voluntarily report changes in your medical expenses for household members that are:
- 60 years old or older - getting veterans’ disability benefits
- disabled spouses or children of a deceased veteran - getting government disability retirement benefits
- getting Supplemental Security Income (SSI) - getting Railroad Retirement disability benefits
- getting Social Security Disability payments - getting disability-based medical assistance
If you report and verify an increase in your medical expenses, you may be eligible for more food stamp benefits. Changes in
medical expenses must be reported at your next recertification.
Temporary Assistance (TA) Reporting Rules: The rules listed above apply only to the Food Stamp program. If you also receive
TA, you are still required to report changes for TA within 10 days of the change, on periodic report mailers, TA Eligibility
Questionnaires and at recertification.

When to use this form:

This form may be used to report any required or voluntary changes. You can also use this form to report changes in the cost of
caring for children or disabled adults, or changes in shelter costs even if you haven’t moved. If these expenses go up you may be
eligible for more food stamp benefits.
If proof of the changes you are reporting is available, please include it with this form. This will help make sure that you get the
correct amount of food stamp benefits. Reported changes must be verified before we can increase your benefits.
This form should be mailed or brought to the agency listed above. If for some reason you can’t mail or bring in this form, you can
report the changes by calling us at the telephone number listed on Page 1.

If you no longer want to receive food stamp benefits, sign here to withdraw from participation in the Food Stamp
program. Your food stamp benefits will stop. You have the right to contest this withdrawal if you feel that you were given
incorrect or incomplete information about your eligibility for food stamp benefits by requesting a Fair Hearing within 90
days. You may re-apply for food stamp benefits at any time after your withdrawal.

X
IF YOU WITHHOLD INFORMATION ABOUT CHANGES IN YOUR HOUSEHOLD THAT YOU ARE REQUIRED TO REPORT, YOU
WILL OWE US THE VALUE OF ANY EXTRA FOOD STAMP BENEFITS YOU RECEIVE AS A RESULT. IF YOU INTENTIONALLY
WITHHOLD INFORMATION WHEN YOU ARE REQUIRED TO REPORT IT, YOU MAY ALSO BE DISQUALIFIED FROM THE
FOOD STAMP PROGRAM AND COULD BE SUBJECT TO CRIMINAL PROSECUTION (SEE ATTACHED “FOOD STAMP
PENALTY WARNING” ON PAGE 6).
PAGE 4 LDSS-3151 (Rev. 1/06)

Use the Form Below to Report Changes

CHANGE IN INCOME OR SOURCE OF INCOME – If you are a Six–Month Reporter, your reporting rules are explained beginning on Page 2.
If you are a Change Reporter, your reporting rules are also explained on Page 2.
HOW OFTEN
NAME OF PERSON RECEIVING INCOME SOURCE OF INCOME NEW AMOUNT
RECEIVED

1. $
2. $
3. $
CHANGE IN HOUSEHOLD - List below all new members to your household including newborn children. Also list members who have moved in
or out or have died.
NAME AGE RELATIONSHIP CHANGE (CHECK ONE) DATE INCOME AMOUNT SOURCE
… CAME INTO HOUSEHOLD
1. … LEFT HOUSEHOLD $
… CAME INTO HOUSEHOLD $
2. … LEFT HOUSEHOLD
… CAME INTO HOUSEHOLD $
3. … LEFT HOUSEHOLD
… CAME INTO HOUSEHOLD $
4. … LEFT HOUSEHOLD
CHANGE OF ADDRESS
NEW MAILING ADDRESS CITY STATE ZIP CODE

IF YOU DON’T HAVE A STREET ADDRESS, GIVE DIRECTIONS TO YOUR HOME (if you are homeless, leave blank) TELEPHONE NUMBER WHERE YOU
CAN BE REACHED
( )
AREA CODE

CHANGE IN HOUSING COSTS - If you have moved, you must list your new costs below. Even if you have not moved, you can use this section
to tell us that your rent, mortgage payment or other costs have changed.
Are you a roomer or boarder? … YES … NO If Yes, are meals … INCLUDED … NOT INCLUDED
RENT YES NO IF YES, GIVE MONTHLY AMOUNT CHANGE (CHECK ONE)

Do you pay rent? … … $ … Same … More … Less

Do you pay for the following separate from your rent? YES NO
• Heat and/or air conditioning … …
• Utilities (electricity, cooking gas, etc.) … …
• Telephone … …
MORTGAGE PAYMENT YES NO IF YES, GIVE MONTHLY AMOUNT CHANGE (CHECK ONE)
Do you have a mortgage payment? … … $ … Same … More … Less
Do you pay for the following separate
from your mortgage: YES NO IF YES, GIVE MONTHLY AMOUNT CHANGE (CHECK ONE)
• Property taxes … … $ … Same … More … Less
• House Insurance … … $ … Same …More … Less
• Heat and/or air conditioning … …
• Utilities (electricity, cooking gas, etc.) … …
• Telephone … …
Are you living in section 8 or
other subsidized housing? … YES … NO Are you living in public housing? … YES … NO
LDSS-3151 (Rev. 1/06) PAGE 5
CHANGE IN NUMBER OF CARS OR VEHICLES - Has anyone in your household purchased, sold or traded a car, truck, boat, camper,
motorcycle or other vehicle since the last time you told us about vehicles?
MAKE MODEL YEAR IF SOLD, AMOUNT RECEIVED

1. $

2. $

3. $
CHANGE IN SAVINGS - List the total amount of money that the members of your household now have.
Include cash, savings accounts, checking accounts, stocks, bonds or other investments. You must tell us if
your household savings have increased to more than $2,000 (more than $3,000 if anyone in your household $
is 60 years old or older or been determined to be disabled).
CHANGE IN CHILD CARE, DEPENDENT CARE COSTS OR THE AMOUNT OF CHILD SUPPORT PAID - Have your child care or
dependent care costs changed? If so, you may be eligible for more Food Stamp benefits.
CHANGE (CHECK ONE) FOR WHOM? WHOM DO YOU PAY? NEW AMOUNT HOW OFTEN DO YOU PAY?

1. … NO LONGER HAVE COST $

… HAVE COST
2. … NO LONGER HAVE COST $
… HAVE COST
3. … NO LONGER HAVE COST $
… HAVE COST
CHANGE IN MEDICAL COSTS (Doctors, Dentists, Hospitals, Prescriptions, etc.) – You are only required to report changes in your
medical expenses at recertification. However, you may voluntarily report changes in your medical expenses at any time for household
members who are:
• 60 years old or older
• disabled spouse or children of a deceased veteran
• getting Supplemental Security Income (SSI)
• getting Social Security Disability payments
• getting veterans’ disability benefits
• getting government disability retirement benefits
• getting Railroad Retirement disability benefits
• getting disability-based medical assistance
If you report and verify an increase in your medical expenses, you may be eligible for more food stamp benefits.
NAME TYPE OF COST AMOUNT HOW OFTEN IS EACH PAYMENT DUE?

DO YOU EXPECT THE CHANGES YOU HAVE REPORTED TO CONTINUE NEXT MONTH? … YES … NO
If “NO”explain:

CHECK HERE IF YOU HAVE NO CHANGES TO REPORT ABOUT YOUR FOOD STAMP HOUSEHOLD … NO CHANGES

BE SURE TO READ AND SIGN PAGE 6 Î

PAGE 6 LDSS-3151 (Rev. 1/06)

CHANGE OF BENEFITS
We will use your answers on this form to see if your household’s benefits will change. Before we change your benefits,
we will send you a notice explaining what will happen. If you don’t agree with our decision, you have the right to a fair
hearing to challenge our decision.

FOOD STAMP BENEFITS (FS) PENALTY WARNING

Any information you provide in connection with your application for Food Stamp Benefits will be subject to verification by
Federal, State and local officials. If any information is incorrect, you may be denied FS. You may be subject to criminal
prosecution for knowingly providing incorrect information.
You will never be able to get FS again if you are:

• Found guilty in a court of law for the second time of buying or selling controlled substances (illegal drugs or
certain drugs for which a doctor’s prescription is required) in exchange for FS: or

• Found guilty in a court of law of selling or obtaining firearms, ammunition or explosives in exchange for FS; or

• Found guilty in a court of law of trafficking in FS worth $500 or more. Trafficking includes the illegal use, transfer,
acquisition, alteration or possession of FS, authorization cards or access devices; or

• Found guilty in a court of law of committing a third Intentional Program Violation (IPV).
You will not be able to get FS for two years if you are found guilty in a court of law for the first time of buying or selling
controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for FS.
If you have committed your:

• First IPV, you will not be able to get FS for one year.

• Second IPV, you will not be able to get FS for two years.
A court could also bar you from receiving Food Stamp Benefits for an additional 18 months.
If you make a false statement about who you are or where you live in order to get multiple FS, you will not be able to get
FS for ten years (or permanently if this is the third IPV).
You may be found guilty of an Intentional Program Violation if you:

• Make a false or misleading statement, or misrepresent, conceal or withhold facts; or

• Commit any act that constitutes a violation of Federal or State law for the purpose of using, presenting,
transferring, acquiring, receiving, possessing or trafficking of food stamp benefits, authorization cards or
reusable documents used as part of the Electronic Benefit Transfer (EBT) system.
You could also be fined up to $250,000, sent to jail for up to 20 years, or both.
CERTIFICATION
I understand the penalty for hiding or giving false information. I also understand I will owe the value of any extra
food stamp benefits I receive because I don’t fully report changes in my household. I agree to prove any
changes reported if necessary. The answers on this form are correct and complete to the best of my knowledge.
I understand that my signature authorizes federal, state and local officials to contact other persons or
organizations to verify the information I have provided.
SIGNATURE DATE