WIXLIB

FAMILY INDEPENDENCE ADMINISTRATIONMatthew Brune, Executive Deputy CommissionerJames K. Whelan, Deputy CommissionerPolicy, Procedures, and TrainingLisa C. Fitzpatrick, Assistant Deputy CommissionerOffice of ProceduresPOLICY BULLETIN #10-85-OPEREVISIONS TO FORMS M-325U, W-34A, W-106E, W-113E, W-145WW,W-145XX, W-208A, W-209B, W-607A, W-608H, W-719E, W-719G, AND W-719RDate:August 16, 2010Subtopic(s):FormsThis procedure cannow be accessed on theFIAweb.The purpose of this policy bulletin is to inform all Job Center staff thatthe following Disbursement and Collection (D&C) forms have beenrevised: Request for Lift of Stop Payment Order (M-325U)Referral/Information Form (W-34A)Notice of Decision on Returned or Released Check (W-106E)Information and Referral Notice (W-113E)Daily Log for Personal Care Kits and Supplementary Items(W-145WW)Weekly Status Report for Personal Care Kits and SupplementaryItems (W-145XX)Home Delivery Sheet of Cash Assistance Checks (W-208A)Daily Emergency Public Assistance (EPA) Check Log (W-209B)Request for Identification Card/Temporary MedicaidAuthorization/Update Existing CBIC (W-607A)Travel Directions to the Manhattan/Brooklyn Common BenefitIdentification Card (CBIC) Over-The-Counter (OTC) Sites(W-608H)Monthly Report of Emergency Public Assistance Checks(W-719E)Carfare Authorization (W-719G)Summary of Audit of Single Issue Forms (LDSS-3575) (W-719R)HAVE QUESTIONS ABOUT THIS PROCEDURE?Call 718-557-1313 then press 3 at the prompt followed by 1 orsend an e-mail to FIA Call Center Fax or fax to: (917) 639-0298Distribution: X

PB #10-85-OPEAll forms have been revised as follows: The New York City logo has been updated.The forms have been formatted in accordance with currentAgency software requirements.The forms have been updated to reflect current Agencyterminology.Additional revisions to Form W-208A: The form has been updated to contain one Home Delivery Sheetrather than two.The date and check number of the CA check are now recorded inone combined column.The delivery date and amount of the CA check are now recordedin one combined column.Additional revisions to Form W-608H: The form has been updated to contain current bus and subwaydirections.Job Center Directors must ensure that all previous versions of therevised forms, and all multilingual equivalents, are removed fromcirculation and recycled.Samples of the revised forms are attached.Effective ImmediatelyAttachments:Please use Print onDemand to obtain copiesof -209BFIA Policy, Procedures, and TrainingRequest for Lift of Stop Payment Order(Rev. 8/16/10)Referral/Information Form (Rev. 8/16/10)Notice of Decision on Returned or ReleasedCheck (Rev. 8/16/10)Information and Referral Notice (Rev. 8/16/10)Daily Log for Personal Care Kits andSupplementary Items (Rev. 8/16/10)Weekly Status Report for Personal Care Kits andSupplementary Items (Rev. 8/16/10)Home Delivery Sheet of Cash Assistance Checks(Rev. 8/16/10)Daily Emergency Public Assistance (EPA) CheckLog (Rev. 8/16/10)2Office of Procedures

PB #10-85-OPEW-607AW-608HW-608H (S)W-719EW-719GW-719RFIA Policy, Procedures, and TrainingRequest for Identification Card/TemporaryMedicaid Authorization/Update Existing CBIC(Rev. 8/16/10)Travel Directions to the Manhattan/BrooklynCommon Benefit Identification Card (CBIC) OverThe-Counter (OTC) Sites (Rev. 8/16/10)Travel Directions to the Manhattan/BrooklynCommon Benefit Identification Card (CBIC) OverThe-Counter (OTC) Sites (Spanish) (Rev. 8/16/10)Monthly Report of Emergency Public AssistanceChecks (Rev. 8/16/10)Carfare Authorization (Rev. 8/16/10)Summary of Audit of Single Issue Forms(LDSS-3575) (Rev. 8/16/10)3Office of Procedures

Form M-325uRev. 8/16/10Request for Lift of Stop Payment OrderJob Center:Date:Case NameCheck NumberCat./Case NumberDate AmountForm M-325uRev. 8/16/10Request for Lift of Stop Payment OrderJob Center:Date:Case NameCheck NumberCat./Case NumberDate Amount

Form W-34ARev. 8/16/10Date:Case Name:Case Number:Referral/Information Form Referral Message Enclosure To (Agency): Inquiry Report From (Agency): Job Center Other Job Center Attention (Name of Agency Representative): Other By (Name of Agency Representative):Applicant/Participant Name:Present Address:Telephone Number:CityStateZip CodeSubject:Comments: Job Center Worker SignatureWorker TitleSupervisor SignatureSection Other Telephone NumberTelephone NumberDateDate

Form W-106ERev. 8/16/10Notice of Decision on Returned/Released CheckTo: Disbursement and Collections UnitFrom: Staff/UnitDateNameCase Number/SuffixAddressAmt. of Check Date of CheckCheck No. RELEASED ABOVE CHECK Supervisor RETURNED ABOVE CHECK SupervisorReason for ReturnForm W-106ERev. 8/16/10Notice of Decision on Returned/Released CheckTo: Disbursement and Collections UnitFrom: Staff/UnitDateNameCase Number/SuffixAddressAmt. of Check Date of CheckCheck No. RELEASED ABOVE CHECK SupervisorDateSupervisorDate RETURNED ABOVE CHECK Reason for Return

Form W-113ERev. 8/16/10Information and Referral NoticeJob Center/OtherToAddressGroup or Section/Job Center/AgencyFrom Group/SectionDateFloorSignature of WorkerName of Applicant/ParticipantRoom No.Tel. NumberFor: Information OnlyReplyReferralCase Type/Number/SuffixAddressMessage/Reply (if referral to another Job Center or agency, give reason)Form W-113ERev. 8/16/10Information and Referral NoticeJob Center/OtherToAddressGroup or Section/Job Center/AgencyFrom Group/SectionSignature of WorkerName of Applicant/ParticipantDateFloorRoom No.Tel. NumberFor: Information OnlyReplyReferralCase Type/Number/SuffixAddressMessage/Reply (if referral to another Job Center or agency, give reason)

Form W-145WWRev. 8/16/10Daily Log for Personal Care Kits and Supplementary ItemsRegistro Diario de Paquetes para el Cuidado Personal y Artículos SuplementariosCase NameNombre del CasoCenter:Case NumberNúmero del CasoNumber of KitsIssuedNúmero dePaquetes EmitidosDescription of Supplementary ItemsIssued (Please Specify)Descripción de Artículos SuplementariosEmitidos (Por Favor Especifíque)QuantityCantidadDate:Applicant SignatureFirma del Solicitante

W-145XXRev. 8/16/10Weekly Status Report for Personal Care Kits and Supplementary ItemsToday's Date:From:Center Director/Designee:Center Location/Number:To:Regional Manager:Address:City:State:Zip Code:Submitted here is a weekly report confirming the number of Personal Care kits as well as Supplementary Itemsissued at our center for the week ending:.Number of Personal Care kits issued:Supplementary Items issued:Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)Quantity:(please specify)D&C SupervisorDate

Form W-208ARev. 8/16/10Home Delivery Sheet of Cash Assistance Checks(Prepare in Triplicate)Center/Division:Case #Date to Center/Div:Name & Address ofParticipant(Last name first)Date &Number ofCheckDateDelivered& Amount1. 2. 3. 4. 5. 6. 7. 8. 9. 10. SignatureRemarks

Form W-209BRev. 8/16/10Daily Emergency Public Assistance (EPA) Check LogSection AThis Section is to be completed by D&C UnitSection BBatch TransmittalThis Section is to be completed by Control UnitJob Center: Date:EPA Check No.Name on LDSS-3575Case No./SuffixAmount nsAuthorizationNumberReason forRejectionDate ofResubmissionDate No. of EPA Checks:Batch No.:[ ] Batch AcceptedPA Check Total:Corrected No. of Forms LDSS-3575:[ ] Batch RejectedPA Grant Batch Total Amount:Attach adding machine tape.D&C SupervisorDateControl Clerk: Date:State Reason and Dispostion:Head Control Clerk: Date:Corrected No. of Forms LDSS-3575:CRT Operator: Date:Head Control Clerk:Head Control Clerk: Date:Initials/Date

Form W-607A (page 1)Rev. 8/16/10Request for Identification Card/Temporary Medicaid Authorization/Update Existing CBICPrepare in the following situations: Replacement of CBIC or Medicaid card Update CBIC Undomiciled applicant/participant Issuance of Immediate Needs/Expedited Food Stamp Grant Authorized representative (payee) case Temporary Medicaid Authorization forapplicant before case is on WMSSection I: (To be completed by JOS/Worker)To: Reception/Disbursement and Collections UnitFrom: Job Center/Food Stamp Office:Case Name:Applicant/Participant's Signature:Authorized Representative (Payee) Name (print):Authorized Representative (Payee) Signature:Finger ant Case Type/Case No./Registry No./Suffix: Applicant/Participant CIN:Caseload:Identification documents witnessed for applicant/participant orauthorized representative; the same two pieces must bepresented to the Disbursement and Collections (D&C) Unit.Check Reason for Action: 01 Lost card 06 Surrendered 02 Stolen 09 First card/never received 03 Defective CBIC update (no CBIC 04 Mutilated referral required)DocumentID NumberSection II: Reason for Request (To be completed by JOS/Worker) Photo card? Is applicant receiving expedited FS Is the mailing address different than that on WMS? No No Yes Yes If yes, complete below.benefits and/or an immediate needsgrant? No Yes Is the payee correctly established? No If No:Care of Name Yes Delete current payee StreetApt. No.CIN Add new payee CityStateZipCIN Mail Permanent Card and Temporary Medicaid Card (LDSS-4113-2) (CBIC menu function 1) Over-the-Counter Permanent Card Request (LDSS-4113-2) (CBIC menu function 2)

Form W-607A (page 2)Rev. 8/16/10Human Resources AdministrationFamily Independence AdministrationSection II: Reason for Request (To be completed by JOS/Worker) Authorized Representative Card (CBIC menu function 3) Be sure to send authorized representative to the AFIS Unit for photo and signature only.Check one: Agency pickup (at OTC Site) Mail Authorized Representative:First NameM.I. Last Name Temporary Medicaid Authorization (LDSS-2831-A) Complete Section IV. JOS/Worker's SignatureDateSupervisor's SignatureDateSection III: Signature Verification (To be completed by D&C or FS Reception) Temporary card (Vault) referral issued Permanent card mail request processed (to be decided by D&C or FS Reception) Applicant/Participant's SignatureDateAuthorized Representative (Payee)SignatureDateSignature(s) verified and documents listed in Section I seen.FS Reception/D&C or Card Producer's Signature:Date:To be Completed by Job Center ONLYSection IV: Additional information for Temporary Medicaid Authorization (LDSS-4113-2/LDSS-2831A)(To be completed by JOS/Worker)LastFirstNameStreetAddress CityStateEnter 7-digit casenumber and 1-digit suffixLeave blank Case NumberCINZip CodeIf enrolled in HIP or HMO plan,enter "P." For all others, enter "A."Enter insurance codeif available. If notavailable leave blank. CategoryLast NameFirst NameSexDate of BirthIns. Cov.Code CodeD&C:If temporary Medicaid card (LDSS-2831A) is issued, please also give the Applicant/ParticipantForm.SSN