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LDSS-3151 - Supplemental Nutrition Assistance Program ...

LDSS-3151 (Rev. 10/15) PAGE 1 NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY Assistance CASE NUMBER Supplemental Nutrition Assistance Program (SNAP) 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: TO: ADDRESS: LOCAL DISTRICT NAME, ADDRESS AND TELEPHONE NUMBER: 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 Supplemental Nutrition Assistance Program (SNAP) benefits and collect the amount of the overpayment from you. The changes that you MUST report are explained below.

supplemental nutrition assistance program (snap) 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: to: address: local district name, address and telephone number: ...

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otda.ny.gov

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otda.ny.gov

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