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 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 Addition To Household o Additional Allowance o Back Mortgage and/or o Back Rent

§ 352.30 for Fuel § 352.5 Taxes § 352.7(g) § 352.7(g)

o Broker's or Finder's o Catastrophic Loss o Furniture and Other o Moving Expenses

Fee/Voucher (replacement of clothing Household Items § 352.6(a)
§ 352.6(a) and furniture lost in fire, § 352.7(a)
flood or other disaster)
§ 352.7(a)

o Payment to Maintain o Pregnancy Allowance o Property Repairs o Rent Security Deposit/

or Restore Utility § 352.7(k) § 352.4(d), § 352.6(e) Letter of Guarantee
Services § 352.5 § 352.6(a)

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)

o Work Activity Related

Supportive Services
§ 385.4
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 Date

Landlord's Signature Date

(Scan one copy of this form and the W-163 into the electronic file.)