How to Fill Out and Submit Form W-137A: Emergency Assistance Request

To fill out Form W-137A, complete only the sections that match your request — emergency assistance, additional allowances, work-related supportive services, or adding someone to your Cash Assistance case — then bring, mail, or fax it to your assigned HRA Job Center. The form is labeled “For Participants Only,” so you use it after you’re already receiving Family Assistance or Safety Net Assistance, not to apply for benefits in the first place.¹

You can pick up a paper copy at your Job Center or download the PDF from the NYC HRA website. One instruction printed on the form itself is worth internalizing before you start writing: submit the form even if you don’t yet have every piece of supporting information. Your worker is expected to help you gather what’s missing.²

How the Form Is Organized

W-137A has four sections. You fill in only the ones that apply to your situation and leave the others blank. Section I is a write-in area for emergencies. Section II is a checklist of additional allowances, split between general special needs and moving-related costs. Section III covers work-activity supportive services. Section IV is for adding a person to your case. Common reasons to file the form include back rent, replacing belongings after a fire, moving expenses, a pregnancy allowance, and adding a newborn or spouse to the household.²

Section I: Emergency Assistance

In Section I you write in the type of emergency you’re facing and explain why you need help. Situations that qualify include risk of homelessness, a gas or electric shut-off or shut-off notice, loss of belongings to theft, fire, or natural disaster, and domestic violence.³

Emergency assistance through HRA is often called a One Shot Deal because it’s typically a one-time grant rather than an ongoing benefit. HRA evaluates each request based on your income, household size, the reason for the emergency, your available savings, and whether you have a realistic plan to cover the same expense going forward. There is no fixed income cutoff that guarantees approval or denial.³

Section II: Additional Allowances

Section II is a checklist. Tick the boxes for what you need and fill in the details the form asks for. The allowances fall into two groups.

General Special Needs

Check any of these that apply:²

Back rent. State regulations limit arrears payments to a total period of six months, and you can generally receive this only once every five years unless your district decides otherwise.
Repair of essential household items, covering heating equipment, cooking stoves, and refrigerators. Replacement is allowed when it costs less than repair.
Back mortgage and/or taxes, when needed to prevent foreclosure.
Pregnancy allowance: a $50 monthly supplement added to your grant starting in the fourth month of pregnancy or when you provide medical verification, whichever comes later.
Restaurant allowance, for people who cannot prepare meals where they live. The daily extra ranges from $29 for dinner only up to $64 for all three meals.
Burial allowance. You or your authorized representative applies separately at the Office of Burial Services, 33-28 Northern Boulevard, 3rd Floor, Long Island City, NY 11101 (718-473-8310).
Additional allowance for fuel, for heating costs beyond what your regular grant covers.
Property repairs, for essential repairs to heating, plumbing, water supply, cooking, and refrigeration equipment.
Replacement of clothing lost to a disaster, with state-set maximums of $48 for children through age five, $73 for ages six through eleven, and $89 for anyone twelve and older.

Dollar figures come from the state schedules in 18 NYCRR 352.7, which also caps furniture-related grants. Your worker cannot award more than the regulation allows for a given item.⁴

Moving-Related Expenses

If you’re relocating, a separate cluster of checkboxes covers moving expenses, furniture and other household items, a security deposit or agreement, storage of furniture and personal belongings, and a broker’s or finder’s fee or voucher.²

When you check any moving-related box, the form also asks for your new address, the date you moved, your new monthly rent, your landlord’s name, and the primary tenant’s name if applicable. Fill in whatever you know.

Section III: Work Activity Supportive Services

Section III covers expenses tied to a work assignment, job search, or training program that HRA has placed you in. The checkboxes are:²

Clothing, for job-search participants facing exceptional circumstances like homelessness or a recent fire who lack appropriate clothing.
Licensing, uniform, or durable goods fees, within approved limits, with documentation that the items are needed for your activity.
Child care allowance, within approved limits, if needed to participate.
Public transportation for getting to and from your activity.
Other work-activity-related services, a write-in line for anything that doesn’t fit the categories above.

Supportive services are provided when you begin a work activity. If your needs change afterward, or if you’re not receiving something you need, this section is how you ask for it.

Section IV: Adding a Person to Your Case

Section IV is for adding a household member. Check the category that fits and provide the person’s name, date of birth, the date they moved in or returned, and their Social Security number if you know it.²

The categories are: new baby; child entered home; child under 18 whose immigration status has changed since your last application or recertification; spouse or adult living with you who has not previously applied; spouse previously denied due to immigration status whose status has since changed; and yourself or an adult payee being added.

One important caveat: if the person you’re adding is a spouse or adult who has never applied, checking the box on W-137A isn’t enough. That person must file their own Cash Assistance application to actually be added.

Documents to Gather

You may be asked to prove what you report on the form, and your worker is required to help you obtain proof you can’t get on your own. Common documentation includes:³

Birth certificate, Social Security card, or photo ID for each adult in the household
Proof of income for all household members
Bills or letters from your landlord showing monthly rent and any arrears
Court orders such as eviction notices or orders of protection
Your lease

For moving requests, add the new lease or rental agreement, a moving-company quote, and documentation of the security deposit. For clothing or furniture replacement after a disaster, a fire department or police report helps verify the loss. Missing paperwork is not a reason to hold the form back; the form itself directs you to submit even when information is incomplete.

How to Submit the Form

The primary way to submit W-137A is in person at your assigned HRA Job Center. Your worker scans and indexes the form into your case file and returns the signed original to you, and you’ll be seen the same day.²

You can also mail or fax the completed form to your worker. Mailing adds processing time, and you won’t get the stamped original back the way you would in person, so keep a copy for your records.

For emergency assistance specifically, you can start a One Shot Deal application online at access.nyc.gov, but even then you must complete an in-person interview before HRA will approve the grant.³

After You Submit

You may be scheduled for an appointment to discuss the request and review your documentation. Housing emergencies and utility shut-offs are handled with more urgency than other requests. HRA sends a written notice of its decision. Approved allowances are added to your case at the amount the state schedule allows.⁴

If Your Request Is Denied

The denial notice will explain the reason. You have the right to request a fair hearing through the New York State Office of Temporary and Disability Assistance to have the decision reviewed, and you must request it within 60 days of receiving the notice.⁵

Online through the OTDA hearings portal at otda.ny.gov/hearings
By phone at 800-342-3334, Monday through Friday, 8 a.m. to 5 p.m.
By fax at 518-473-6735
By mail to NYS OTDA, Office of Administrative Hearings, P.O. Box 1930, Albany, NY 12201-1930
In person at the Office of Administrative Hearings, 14 Boerum Place, Brooklyn, NY 11201, Monday through Friday, 8:45 a.m. to 4:30 p.m.

Bring your copy of the W-137A, the denial notice, and any supporting documents to the hearing.

1
NYC Human Resources Administration. Cash Assistance – HRA
2
NYC Human Resources Administration. NYC HRA Form W-137A – Request for Emergency Assistance, Additional Allowances, or to Add a Person to the Cash Assistance Case
3
ACCESS NYC. Emergency Assistance / One Shot Deal
4
Legal Information Institute (Cornell Law School). New York Comp. Codes R. and Regs. Tit. 18 352.7
5
NYC 311. Public Benefit Fair Hearing