046

Crotona Job Center

1910 Monterey Ave, 6th Fl
Bronx, NY 10457

FTDAATDTTAFTAAFATFFFADATDDDDFFDFDAAADTFAAAFADDDFDDFFDDTFTATFFDFTD

GEORGIA ROMEO
688 EAST 223 STREET Apt 1
BRONX, NY 10466-4002
 FIA-1204 (E) 02/22/2023 (page 1 of 3) LLF
046

1910 Monterey Ave, 6th Fl Date: 07/12/2023

Center Number: 046
Bronx NY 10457
Case Name: ROMEO GEORGIA

GEORGIA ROMEO Case Number: 00039380159C

Application File Date: 07/12/2023
688 EAST 223 STREET
Apt 1
BRONX NY 10466

Interview Required for Your Cash Assistance Application!

We received your Cash Assistance (CA) application. You must contact us to be interviewed.

You should contact us by 07/17/2023 .

If you have an emergency or an immediate need, contact us right away.

You can call Monday – Friday 8:30am to 5:00pm

Note: Our offices are closed on Saturdays, Sundays, and legal holidays.

You have thirty (30) days to complete your interview or you application will be denied.

(Please ignore this notice if you already completed your interview!)

Call NOW. (929) 273-1872

Your interview will take about 30-60 minutes.

Can’t call today?

Many people find it helpful to write down a plan to call. Write down your
plan and put a reminder in your phone to help you remember.

I will call: _______________ at ______________________.

Monday - Friday between 8:30am - 5:00pm

Or you may visit a Benefits Access Center to have an interview. Call

311 or visit www.nyc.gov/site/hra/locations/locations.page to find the
one most convenient for you.

(Turn page)
FIA-1204 (E) 02/22/2023 (page 2 of 3) Human Resources Administration
LLF Family Independence Administration

What will I need for the call?

Only your Cash Assistance Case Number (at the top of page 1 of this notice) or your ACCESS
HRA Confirmation Number or a Social Security Number (SSN). This will help us find your case.

Who needs to be interviewed?

All members of the case that are 18 years or older should be available during the interview.

What documents will I need?

You will need to give us documents that prove the information you gave us on your application. If
you had a case before, we may have documents from you that can be used again.

You can give us documents after your interview. You will be given at least 10 calendar days after
your interview to give us any documents we ask for.

For each person who is applying, you must give documents that prove:

X Identity
X Income
X Members of your household (the people you live with)

For each person who is applying, you may need to give documents that prove:

X Citizenship or
X Current immigration status

You will need to give documents that prove your home address (if you have one), and the number
of people you live with.

You may need to give us additional documents. The Eligibility Factors and Suggested
Documentation Guide (W-119d), we sent with this notice, lists examples of documents that you
can use.

úg
c
d
e
f
Upload any required documentation via the ACCESS HRA mobile app that you have
not already submitted (more info: www.nyc.gov/hradocs).

You do not need to return this form.

(Turn page)
FIA-1204 (E) 02/22/2023 (page 3 of 3) Human Resources Administration
LLF Family Independence Administration

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. Use the
Help For People With Disabilities form in this mailing. You can also call us at 718-557-
1399. 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.
HRA-102c (E) 01/05/2017 (page 1 of 2) LLF

HELP FOR PEOPLE WITH DISABILITIES

Do you have a disability, medical condition or mental health condition that makes it hard for
you to apply for or get benefits from us?

For example:
z Does your condition make it hard for you to use public transportation?
z Do you need help to get to appointments?
z Does your condition make it hard for you to wait for long periods of time?
z Is it hard for you to read, understand or fill out forms?
z Do you need help because of a vision or hearing disability?
z Do you need other help because of your condition?
If you do, we may be able to help you. This help is called a reasonable accommodation.

HOW TO ASK FOR A REASONABLE ACCOMMODATION

V ASK: You can ask for help when you come to an HRA office or center

 CALL: 212-331-4640

You can also write us or fill out the request on the other side of this form and give it to us
through:

 FAX: 212-331-4685

 EMAIL: ConstituentAffairs@hra.nyc.gov

 MAIL: HRA
Office of Constituent Services
150 Greenwich Street, 35th Floor
New York, NY 10007

GET HELP WITH THIS FORM!

You can get help with this form or with your request.

CALL: 212-331-4640 or VISIT: your center or HRA office

Turn this page over to complete the Reasonable Accommodation Request Form. ¨
 HRA-102c (E) 01/05/2017 (page 2 of 2) LLF

HELP FOR PEOPLE WITH DISABILITIES

REASONABLE ACCOMMODATION REQUEST FORM

Do you have a disability, medical condition or mental health condition that makes it hard for you to
apply for or get benefits from us? If you do, please fill out this form. If you do not, you don't need to
fill out this form.
YOUR INFORMATION
Name: Date:
Case Number: Date of Birth:
Phone Number 1: Phone Number 2 (if any):
Address:

WHY DO YOU NEED HELP?

Tell us how your condition makes it hard to access HRA benefits and services (If you need more
space to write, please attach pages):

CHOOSE WHAT HELP YOU MIGHT NEED BECAUSE OF YOUR CONDITION:

Help for people who are blind Help for people who are deaf or hard of hearing :
or low vision
Explain: American Sign Language (ASL) interpretation
Making appointments when you can Other forms of interpretation
have someone come with you Explain:
Help reading forms
No appointments during certain
days and times Help completing forms
No appointments during rush hour You need HRA to come to your home
for appointments
No in-office appointments while you Transfer your case to center:
apply for Access-A-Ride
Shorter wait times Keep your case at your center:

Accommodations (other than above) that you need to access services at HRA. Explain:

You do not need to give us proof of your condition now.

We may ask you to give us some medical or clinical documents later.

To be completed by HRA worker if submitted at an HRA location (Please give a copy to the client):

Location Date Received

Name of HRA worker (Print) Signature

Center 90 Staff only: Homebound status was requested Yes No

Form W-119D (page 1 of 5) LLF
Rev. 11/28/2022

Eligibility Factors and Suggested Documentation Guide

To prove this factor,
provide: ONE of the
Eligibility Factor following  OR TWO* of the following:
Identity  Photo I.D. Statement from another person
You must establish identity for each person listed.  Driver’s license Birth/baptismal certificate
 U.S. passport Validated Social Security Number
 Naturalization certificate (SSN)
 Hospital/Doctor’s records
 Adoption papers

Marital Status  Marriage/Death certificates  Statement from clergy

You must prove if you are married, divorced, separated  Separation agreement  Census records
or widowed (not required for the Supplemental Nutrition  Divorce decree  Newspaper notice
Assistance Program [SNAP]).  Social Security records  Statement from another person
 Department of Veterans Affairs (VA)
records
 Birth certificate (long form)  Applicant’s statement
Relationship  Newspaper notice
 Adoption papers/records
If you are related to a child in the household, you must  Statement from clergy
prove the relationship.  Court records
 Medical records  Statement from another person

Residence  Statement from landlord/primary  Statement from another person

You must verify your place of residence tenant  Current mail
(if applicable).  Current rent receipt or lease
 Mortgage records

Household Composition/Size  Statement from nonrelative landlord  Statements from other persons
You must prove who is living with you.
*At recertification only required for minors if
questionable

Age  Birth certificate  Insurance policy

You must prove the age of each person applying for  Baptismal records/certificate  Census records
assistance, where appropriate.  Hospital records  Statement from another person
 Adoption papers/records  Physician statement
 Naturalization certificate  Official correspondence from
 Driver’s license Social Security Administration (SSA)

Absence/Death of Parent(s)  Death certificate  Newspaper notice

If the parent(s) of any child in your home is not living  Survivor’s benefit records  Insurance company records
with you, you must prove this (not required for SNAP).  Hospital records  Institutional records
 VA or military records  Agency case records and burial
 Divorce papers payment files
 Proof of remarriage  Statement from another person

Absent Parent Information  Pay stubs NA

If the parent(s) of any child in your home is not living  Tax returns
with you, you must provide information you have about  Social Security or VA records
the individual’s: name, address, SSN, birth date, and  Monetary determination letters
employment (not required for SNAP).  ID cards (health insurance)
 Driver’s license or registration

Social Security Number  Social Security card NA

For Temporary Assistance, SNAP Benefits and Medical  Official correspondence from SSA
Assistance only, you do not have to provide proof of A Social Security number is not required for
your SSN unless the SSN you give does not match the non-citizens who are seeking Medical
SSA’s records or cannot be verified by the Agency. Assistance for emergency treatment only or
are Medical Assistance – only applicants
who are pregnant.

*If you are applying for Supplementary Nutrition Assistance Program (SNAP) benefits or Medical Assistance only, you need to
bring one form for each Eligibility Factor checked.

(Turn page)
Form W-119D (page 2 of 5) LLF Human Resources Administration
Rev. 11/28/2022 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Eligibility Factor To prove this factor,

provide ONE of the following:
Citizenship or Current Immigration Status  Birth certificate
Status – U.S. citizens are eligible for Temporary Assistance, the  Baptismal certificate/records
Supplemental Nutrition Assistance Program and medical  Hospital records
assistance. Non-citizens must be in a satisfactory immigration status  U.S. passport
in order to be eligible for Temporary Assistance, the Supplemental
Nutrition Assistance Program and medical assistance. Immigration  Military service records
status is not an eligibility factor for pregnant women or immigrant  Naturalization certificate
children applying for Child Health Plus B. Non-citizens without an  USCIS documentation (e.x., Green Card, Forms I-551, I-94,
immigration status and temporary nonimmigrants are eligible only I-797, etc.)
for the treatment of an emergency medical condition.  Evidence of continuous U.S. residence since prior to 1/1/72

Earned Income

From employer  Current wage stubs and statements of tips

 Pay envelopes
If you have recently lost your job, you do not have to  Contact with employer
submit verification of your income from employment.  On letterhead, rate of pay per hour, hours worked per week, first pay
date, if new and employer’s phone number
 Business records
From self-employment
 Tax records
 Records and related materials concerning self-employment earnings
and expenses
 Current income tax return
Income from rent or room/board  Current contribution check
 Statement from roomer, boarder, tenant
 Income tax record

Unearned Income
 Statement from Family Court
Child Support received from the non-custodial parent.  Statement from person paying support
 Check stubs
 Official correspondence from the Child Support Enforcement Unit
 Current award certificate
Unemployment Insurance Benefits (UIB)  Official correspondence with New York State Department of
Labor (including emails)
 Screen shots or images of benefit statement from Department of Labor
(must include identifying information like your name)
Social Security benefits (including SSI)  Current award certificate/letter
 Current benefit check
 Official correspondence from SSA
Veteran’s benefits  Veterans Affairs official correspondence
 Current award certificate/letter
 Current benefit check
Worker’s Compensation  Award certificate/letter
 Check stub

Education grants and loans  Statement from school (including emails and screen shots)
 Statement from bank (including emails and screen shots)
 Statement from agency administering grant/award letter
 Statement from bank or credit union (including emails and
Interest/dividends/royalties
screen shots)
 Statement from broker/financial institution/agent (including
emails and screen shots)

(Turn page)
Form W-119D (page 3 of 5) LLF Human Resources Administration
Rev. 11/28/2022 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Eligibility Factor To prove this factor,

provide ONE of the following:
Unearned Income (continued)

Private pension/annuity  Current award letter

 Current benefit check
 Official correspondence from source of income
 Contact with source of income
 Current contribution check

Other unearned income

Resources
(For Medical Assistance only, resource information is not requested from
pregnant women, children under the age of 19, and persons eligible for
Family Health Plus.)

Bank Accounts: Checking, savings, retirement (IRA and  Current bank records (including screen shots or electronic
Keogh), credit union statements)
 Current credit card records (including screen shots or electronic
statements)

Stocks, bonds, certificates and mutual funds  Stock/bond certificate

 Statement from financial institution

Life insurance
 Insurance policy
 Statement from insurance company

Burial trust or fund, burial plot, or funeral agreement  Bank records

 Burial agreement
 Burial plot deed

Income tax refund or Earned Income Tax Credit (EITC)  Refund of EITC check
 Statement from tax office

Real estate other than residence  Deed

 Statement from real estate broker
 Broker’s appraisal/estimate of current value by broker

Motor vehicle  Registration (older models)

 Title of ownership
 Appraisal of current value by dealer
 Financing data

Lump sum payment  Statement from the source of payment

 Lump sum check

Other resources  Statement from household

 Statement from nursing home
 Household statement of current value
 Sales slips
 Insurance appraisal

(Turn page)
Form W-119D (page 4 of 5) LLF Human Resources Administration
Rev. 11/28/2022 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Eligibility Factor To prove this factor,

provide ONE of the following:
Shelter Expenses  Current rent receipt/lease/mortgage book/records
 Property and school tax records
You must prove how much it costs you to live where you do. (You may
need to provide separate documentation for each item of shelter  Landlord statement
expense.)  Sewer and water bills
 Garbage/trash collection bills or receipts
You must submit proof of your shelter expenses, if you have any, even if  Homeowner’s insurance records
you have not paid your rent
 Fuel bills/shut-off notice
 Nonheating utility bills
Medical Assistance does not require documentation of shelter  Telephone bills (or a statement from the household that the
expenses. expense is incurred)

Medical Expenses  Statement from provider of health insurance premiums

 Copies of medical bills (paid and unpaid)
For SNAP, for aged/disabled individuals only  Medicare prescription drug card
 Other proof of medical expenses that are not reimbursed (e.x.,
receipts from drug store, proof of payment for hearing aide, etc.)

Health Insurance  Insurance policy/card

 Statement from provider of coverage
If you or anyone applying has health insurance coverage (even if paid for  Medicare card
by someone else), you must prove this.  Separation or divorce agreement with court-ordered health
coverage

Disability/Incapacitation/Pregnancy  Statement from doctor, clinic or hospital verifying pregnancy,

expected date of birth (a sonogram is not acceptable proof)
If you or anyone living with you is sick or pregnant, you must provide  Statement from medical professional
proof. (For MA only, resource information is not requested from pregnant  Proof of SSA/SSI benefits for disability/blindness
women, children, and persons eligible for Family Health Plus).

Unpaid Bills  Copy of each bill showing amount owed, period of services,
and provider of services
Rent, utility

Referral
Drug/alcohol treatment program  Statement from provider of treatment

Employment service  Statement from employment service

Other Expenses/Dependent Care Cost  Court order

 Statement from day care center or other child care provider
You must provide proof if you pay court-ordered support, child care,  Statement from aide or attendant
recurring loans, or for the services of a home health aide or attendant.
 Canceled checks or receipts

School Attendance  School records (current report card)

You must prove who is in school.  Statement from school or higher education institution
 Other proof of school attendance

(Turn page)
Form W-119D (page 5 of 5) LLF Human Resources Administration
Rev. 11/28/2022 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Eligibility Factor To prove this factor,

provide ONE of the following:
Past Management
(For Safety Net Assistance)
 Letter from employer giving dates of employment, amount earned and
Earned Income reason(s) for leaving
 If your most recent employer is closed or no longer in business, please give
us the employer's last known address and telephone number. You must
sign the statement and date it for our records.

If you were not supporting yourself from employment/earned income, please

Other
bring verification of how you were able to support yourself in the past such as:
(For cash assistance only)
 Bankbook/bank statement
 Verification of expiration of benefits, including emails and
screen shots (workers’ compensation, disability, Social Security,
UIB, etc.)
 Statement from person(s) who provided support
Statement from person(s) who provided support
Potential Benefits
 If you or anyone in the household has applied for and been
denied or has been accepted for benefits from any of the following
sources, bring the award letter, check or other correspondence:
Social Security, court payments, SSI, veteran’s benefits, workers’
compensation, union benefits, pension, military allotment, railroad
retirement, NYS disability or other source

Other