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Rev. 6/5/09
Date:
Case number:
Case Name:
Center:
Worker
Telephone No.:
FH&C
Telephone No.:
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.
þ Your Request for additional allowances has been accepted. You will receive:
þ One payment in the amount of $ . Period covered, if applicable: .
Method of payment:
o Broker's or finder's fee/voucher 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 Repair of Essential o Restaurant Allowance o Semimonthly Fuel for o Storage of Furniture and
Household Items § 352.7(c ) Heating Allowance Personal Belongings
§ 352.7(b) § 352.5(b) § 352.6(f)
Date:
Case number:
Case Name:
Center:
Dear: :
Landlord's Name
(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
(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)
B. You are required on an annual basis to remit all interest on the deposit to: