Ldss 3421 Form – Fill Out and Use This PDF

LDSS 3421 Form is an important document for those entering the New York State Home Relief work registration process. It's purpose is to provide evidence that you have completed all necessary background checks and additional steps in order to be considered for entry into the DHS Home Relief Program in New York. The form must include information regarding prior attempts at getting public assistance, proof that you qualify financially for the program, and any other pertinent data that demonstrates your eligibility. Once filled out, it must be submitted directly to a social services office in order to be processed. Being familiar with the required LDSS 3421 Form is key to successfully registering in the Home Relief Program of attendance in New York.

Ldss 3421 Form PDF Details

Are you a taxpayer who needs to fill out Form LDss 3421? If so, we’re here to help! Knowing how to accurately fill out and submit all forms related to taxes can be difficult, especially when there are multiple options from which to choose. That’s why it’s important to make sure that you fully understand the instructions for any form—including the LDss 3421 Form—before submitting your paperwork. In this blog post, we will provide an overview of this form and explain its purpose as well as what information needs to be included on it. With our simple advice, you'll have everything you need in order get through this process with ease!

Question	Answer
Form Name	Ldss 3421 Form
Form Length	18 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 30 sec
Other names	ny heap application pdf, printable heap application, heap application pdf, ldss 3421 fillable

Form Preview Example

LDSS-3421 (Rev. 6/11)

2011-12

HOME ENERGY ASSISTANCE PROGRAM APPLICATION

Home Energy Assistance Program

ANSWER ALL QUESTIONS. DO NOT WRITE IN THE SHADED AREAS. PLEASE PRINT CLEARLY, AND SIGN THE FORM ON PAGE 5.

COMPLETE THE WHITE BOXES BELOW

AGENCY USE ONLY

DSS	OFA/ALTERNATE CERTIFIER

CONTACT THE AGENCY ABOVE IF YOU NEED HELP

DATE RECEIVED

AGENCY USE ONLY

OFFICE

APPLICATION DATE

UNIT ID

WORKER ID

CASE

CASE NUMBER

REGISTRY NUMBER

VERS.

TYPE

CASE NAME

NUMBER

HEAP

REGULAR  HEATING EQPT

REUSE

INCOME

EMERGENCY

 OTHER_____________

INDICATOR

CODE

SECTION 1: HOUSEHOLD COMPOSITION

APPLICANT INFORMATION

FIRST NAME

LAST NAME

OTHER NAMES BY WHICH I HAVE BEEN KNOWN ARE:

NAME

STREET ADDRESS

APT. #

CITY

STATE

ZIP CODE

COUNTY

LENGTH OF TIME AT THIS ADDRESS?

YEARS__________

MONTHS__________

DAYTIME PHONE NUMBER WHERE I CAN BE REACHED (Area Code + Phone No.)

BEST TIME TO CALL

MY MAILING ADDRESS (IF DIFFERENT FROM ABOVE) IS:

ADDRESS

APT. #

CITY

COUNTY

STATE

ZIP CODE

HAVE YOU EVER APPLIED FOR HEAP? YES

NO

IF YES, ENTER DATE OF MOST RECENT APPLICATION 

LIST EVERYONE INCLUDING YOURSELF WHO CURRENTLY LIVES IN THE SAME DWELLING (If no one else, write NONE UNDER YOUR NAME):

DATE OF

CITIZEN /

BLIND

SEX

FIRST NAME

LAST NAME

BIRTH

RELATION

SOCIAL SECURITY

NATIONAL

MO.

DAY

YR.

M/F

TO ME

NUMBER

DISABLED

QUALIFIED ALIEN

SELF

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

Yes

 No

TOTAL NUMBER IN HOUSEHOLD

If there are more members in your household, please attach a separate sheet of paper.

DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET FOOD STAMP BENEFITS?

Yes  No If yes, who? ___________________________________________ FS CASE NUMBER

DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET TEMPORARY ASSISTANCE?

Yes  No If yes, who? ___________________________________________ TA CASE NUMBER

LDSS-3421 (Rev. 6/11)

PAGE 2

SECTION 2: HOUSING – CHECK () ONE BOX ONLY

HOMEOWNER

RENTER

 Single Family House or Mobile Home

 Private House, Apartment or Mobile Home

 Multi-Family House; List Number of Units ____

 Private Subsidized Housing

 Co-op/Condo Owner

 Public Housing Project or Senior Housing

OTHER

 Public Subsidized Housing

 I live with someone else and share expenses

 I pay for a room or room and board

 Permanent hotel/motel

 Other living situation _______________________________

MY MONTHLY RENT OR MORTGAGE PAYMENT IS:

$ ________________________  NONE

IF APPLICABLE, THE NAME OF THE APARTMENT BUILDING OR HOUSING PROJECT I LIVE IN IS: ___________________________________

DO YOU OR DOES ANYONE IN YOUR HOUSEHOLD RECEIVE A SENIOR CITIZEN RENT INCREASE EXEMPTION(SCRIE)?

Yes

No

SECTION 3: HEAT AND UTILITY INFORMATION

IF YOU PAY FOR YOUR OWN HEAT,

OIL AND/OR KEROSENE HEATERS,

COMPLETE SECTION A BELOW:

COMPLETE SECTION B BELOW:

A. My main source of heat is

B. Do you have a written service contract?

 No

 Yes, provide a copy

 Fuel Oil

 Natural Gas

Wood/Wood Pellets

IF YOU DO NOT PAY FOR YOUR OWN HEAT,

 Coal or Corn

 Kerosene

 Propane or Bottle Gas

COMPLETE SECTION C BELOW:

 PSC Electric

 Municipal Electric

 Individual Tank

C. My household situation is:

 Metered Tank

Is the heating bill in your name?  Yes

 No

If No, the bill is in the name of: ___________________________

 Both Heat and Utilities are included in the rent

Relationship to you: ________________________

 Heat is included in rent but I pay for utilities (lights/cooking/hot

water). (Complete information below if checked)

Are you directly responsible to pay the bill?  Yes  No

Is the bill in your name?  Yes  No

Your heating account number is:

If No, the bill is in the name of: __________________________

 Please check if this is a landlord’s account number

Relationship to you: ____________________________

Your heating company’s name is:

Are you directly responsible to pay the bill?

 Yes  No

Your utility account number is:

STREET ADDRESS

 Please check if this is a landlord’s account number

CITY/TOWN

STATE

ZIP CODE

Do you also pay a utility company directly for your lights or

Your utility company’s name is: _____________________________

cooking or hot water?

 Yes  No

If yes, complete

information below

Is electric necessary to run the furnace?

 Yes

 No

Your utility account number (if you have one) is:

Is electricity necessary to operate the thermostat in your

 Please check if landlord’s account number

apartment?

 Yes

 No

Your utility company’s name is:

Is electric necessary to run the furnace?

 Yes

 No

Is electricity necessary to operate the thermostat in your

apartment?  Yes

 No

LDSS-3421 (Rev. 6/11)	PAGE 3
	SECTION 4: HOUSEHOLD INCOME

REPORT ANY INCOME FOR ALL HOUSEHOLD MEMBERS. ALL AMOUNTS MUST BE REPORTED AS GROSS MONTHLY INCOME BEFORE ANY DEDUCTIONS. ATTACH ADDITIONAL SHEETS IF NECESSARY.

CHECK ONE (√)	TYPE OF INCOME	IF YES, GIVE AMOUNT	ADDITIONAL INFORMATION	WHO
		(Gross Monthly Amount		RECEIVES?
		before deductions)
	SOCIAL SECURITY/including direct deposit	MONTHLY AMOUNT	Indicate amount you pay for :
	SOCIAL SECURITY/including direct deposit		Medicare
 No  Yes		$	Part B:
			Medicare
			Part D:

	SOCIAL SECURITY DISABILITY/including direct deposit	MONTHLY AMOUNT	Indicate amount you pay for :
	SOCIAL SECURITY DISABILITY/including direct deposit		Medicare
 No  Yes		$	Part B:
 No  Yes		$	Medicare
			Medicare
			Part D:

	SUPPLEMENTAL SECURITY INCOME (SSI)	MONTHLY AMOUNT
 No  Yes	SUPPLEMENTAL SECURITY INCOME (SSI)	$
	PENSION/RETIREMENT Private and/or government	MONTHLY AMOUNT	Source of Pension
 No  Yes	PENSION/RETIREMENT Private and/or government	$

	VETERAN’S BENEFITS	MONTHLY AMOUNT
 No  Yes		$
 No  Yes		$
	DISABILITY private or NYS	WEEKLY AMOUNT	Source
 No  Yes	DISABILITY private or NYS	$
	CONTRIBUTION from someone outside the household	MONTHLY AMOUNT	Name of Contributor
 No  Yes	CONTRIBUTION from someone outside the household	$
	CHILD SUPPORT	WEEKLY AMOUNT	Source
 No  Yes	CHILD SUPPORT	$
	ALIMONY including payments for mortgage, utility bills,	MONTHLY AMOUNT	Source
 No  Yes	etc.	$
	RENTAL INCOME apartment, garage, land, etc.	MONTHLY AMOUNT	Type of Rental
 No  Yes	RENTAL INCOME apartment, garage, land, etc.	$
	ROOM/BOARD (received) etc.	MONTHLY AMOUNT	Name of Room/Boarder
 No  Yes	ROOM/BOARD (received) etc.	$
	WORKER’S COMPENSATION	WEEKLY AMOUNT
 No  Yes	WORKER’S COMPENSATION	$
	UNEMPLOYMENT BENEFITS	WEEKLY AMOUNT	Start Date:
 No  Yes	UNEMPLOYMENT BENEFITS	$
			End Date:

 No  Yes	INTEREST from savings, checking, CDs, money market
 No  Yes	accounts, etc.	ENTER INFORMATION ON PAGE 4
 No  Yes	DIVIDENDS from stocks, bonds, securities, etc.	ENTER INFORMATION ON PAGE 4
 No  Yes	DIVIDENDS from stocks, bonds, securities, etc.
	WAGES	 WEEKLY $	Employer
 No  Yes		 BI-WEEKLY $
 No  Yes	SUBMIT WAGE STUBS FOR THE PAST 4 WEEKS.	 MONTHLY $
		 WEEKLY $	Employer
		 BI-WEEKLY $
	Note: Gross Weekly amounts are multiplied by	 MONTHLY $
	4.3333 to calculate the monthly amount.
	4.3333 to calculate the monthly amount.	 WEEKLY $	Employer
		 WEEKLY $	Employer
	Gross Bi-Weekly amounts are multiplied by	 BI-WEEKLY $
	2.1666 to calculate the monthly amount.	 MONTHLY $
		 WEEKLY $	Employer
		 BI-WEEKLY $
		 MONTHLY $

 No  Yes	IS THERE ANY OTHER INCOME FROM ANY OTHER	AMOUNT	Source
	IS THERE ANY OTHER INCOME FROM ANY OTHER	$
	SOURCE? ATTACH EXPLANATION

	SELF-EMPLOYMENT INCOME______________________ TYPE OF BUSINESS ______________________________
 No  Yes	If yes, you may choose to have your self- employment income calculated based on your filed federal tax return for the current year or
 No  Yes	prior tax year if you have not yet filed for the current year, including all applicable schedules or based on the three (3) months prior to
	your application. Please choose one method:
	 Filed Federal Tax Return	 Past Three Months

PLEASE SIGN APPLICATION ON PAGE 5

LDSS-3421 (Rev. 6/11)

PAGE 4

IS THERE ANYONE IN YOUR HOUSEHOLD WHO DOES NOT HAVE ANY INCOME FROM ANY SOURCE? LIST ONLY HOUSEHOLD MEMBERS AGE 18 AND OLDER.

No  Yes, list members with no income:

IS ANYONE IN YOUR HOUSEHOLD A FULL-TIME DEPENDENT HIGH SCHOOL OR COLLEGE STUDENT?

No  Yes, Who ________________________________________

________________________________________

INTEREST & DIVIDEND INCOME

TYPE OF INCOME	IF YES, LIST AMOUNT
TYPE OF INCOME	IF YES, LIST AMOUNT	ADDITIONAL INFORMATION
	RECEIVED FOR LAST 12	ADDITIONAL INFORMATION
	RECEIVED FOR LAST 12
	MONTHS
INTEREST from savings, checking, CDs, money market accounts, etc.	ANNUAL AMOUNT	Name of Bank
	$
	$
INTEREST from savings, checking, CDs, money market accounts, etc.	ANNUAL AMOUNT	Name of Bank
	$
	$
INTEREST from savings, checking, CDs, money market accounts, etc.	ANNUAL AMOUNT	Name of Bank
	$
	$
INTEREST from savings, checking, CDs, money market accounts, etc.	ANNUAL AMOUNT	Name of Bank
	$
	$
DIVIDENDS from stocks, bonds, securities, etc.	ANNUAL AMOUNT	Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc.	$
	$
DIVIDENDS from stocks, bonds, securities, etc.	ANNUAL AMOUNT	Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc.	$
	$
DIVIDENDS from stocks, bonds, securities, etc.	ANNUAL AMOUNT	Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc.	$
	$
DIVIDENDS from stocks, bonds, securities, etc.	ANNUAL AMOUNT	Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc.	$
	$

AUTHORIZED REPRESENTATIVE

You can authorize someone who knows your household circumstances to apply for HEAP benefits for you. This person is called your Authorized Representative. Your Authorized Representative may: complete and file your HEAP application, contact the agency and speak with your worker, have access to eligibility information in your case file, complete and sign all forms for you, provide documentation, appeal agency decisions, and receive forms and notices. The Authorized Representative designation will remain in effect for the current HEAP season unless revoked by you. Each HEAP season you will be asked if you want to designate an Authorized Representative.

Please check this box if you would like to authorize a HEAP Authorized Representative at this time.

Please check this box if you would like your Authorized Representative to get letters about your benefits.

You told us that you want someone to be your Authorized Representative for HEAP. Please provide us with the following information about the individual you want as your Authorized Representative.

Name of authorized representative:

Address and phone number:

PLEASE SIGN APPLICATION ON PAGE 5

LDSS-3421 (Rev 6/11)	PAGE 5
	SECTION 5: IMPORTANT NOTICES

IMPORTANT NOTICE

YOU SHOULD BE AWARE THAT THERE IS LIMITED MONEY AVAILABLE FOR HEAP BENEFIT PAYMENTS. ONCE AVAILABLE MONEY IS USED UP, NO BENEFITS WILL BE ISSUED. THEREFORE, IT IS STRONGLY RECOMMENDED THAT YOU COMPLETE AND RETURN YOUR APPLICATION AS SOON AS POSSIBLE. BE AWARE THAT IN PAST YEARS THE PROGRAM HAS CLOSED DOWN AS EARLY AS MARCH 12.

LIFELINE – If you are applying for Lifeline the Office of Temporary and Disability Assistance may or may not release your name and address to your telephone service provider. Your telephone service provider may or may not use this information to enroll you in their Lifeline Service for a discounted telephone rate.

If you DO NOT want this information released, check this box .

You may contact your telephone service provider directly for enrollment in the discounted rate Lifeline Service.

PERSONAL PRIVACY LAW - NOTIFICATION TO CLIENTS

The State’s Personal Privacy Protection Law, which took effect September 1, 1984, states that we must tell you what the State will do with the information you give us about yourself and your family. We use the information to find out if you are eligible for the Home Energy Assistance Program and, if so, for how much. The section of the Law that gives us the right to collect the information about you is Section 21 of the Social Services Law. To make sure that you are getting all of the assistance you and your family are legally entitled to receive, we check with other sources to find out more about the information you have given us. For example:

We may check to find out if you or anyone in your household were working. We do this by sending your name and Social Security Number to the State Department of Taxation and Finance, and also to known employers, to tell us whether you worked and, if so, how much you made.

We may ask the State to check with the Unemployment Insurance Division to see if you or anyone in your household were getting unemployment benefits.

We may check with banks to make sure we know about any income you or anyone in your household may have received.

Besides using the information you give us in this way, the State also uses the information to prepare statistics about all the people receiving Home Energy Assistance. This information is used for program planning and management. The information is used for quality control by the State to make sure local districts are doing the best job they can. It is used to verify who your energy supplier is and to make certain payments to such vendors. Your failure to provide us with the information we need may prevent us from finding out if you are eligible for assistance and we may then have to deny your application. This information is kept by the Deputy Commissioner, Division of Information Technology (DoIT), Office of Temporary and Disability Assistance, 40 North Pearl Street, Albany, New York 12243-0001. Do not send your application to this address. If you or anyone in your household does not have a Social Security Number, a Social Security Number must be applied for at the U.S. Social Security Administration.

Read the Important Information Below

I swear and/or affirm that the information given on this application and subsequent phone interviews is true and correct. I realize that any false statements or other misrepresentation knowingly made by me in connection with this application and subsequent requests for HEAP assistance may result in my being found ineligible for the assistance paid to me or on my behalf. Additionally, any false statement or misrepresentation knowingly made by me for purposes of obtaining assistance under this program may result in an action against me which may subject me to civil and/or criminal penalties. I understand that by signing this Application/Certification, I consent to any investigation to verify or confirm the information I have given and any other investigation by any authorized government agency in connection with this and subsequent requests for Home Energy Assistance Program benefits for the current HEAP season. I also

consent to allow the information provided on this application to be used in referrals to the Weatherization Assistance Program and to my utility company’s low income programs.

TO GET HEAP ALL QUESTIONS MUST BE ANSWERED AND YOUR APPLICATION MUST BE SIGNED AND DATED BELOW.

SIGN HERE: X	DATE SIGNED
SIGN HERE: X
NAME OF PERSON, IF ANY, WHO ASSISTED YOU:	PHONE NUMBER:

LDSS-3421 (Rev. 6/11)PAGE 6

AGENCY USE ONLY

APPLICATION TYPE:  Full Documentation		 Simplified
Vendor	Account Number		Vendor Code	Vendor Relationship:	Current Bill/Vendor Statement
				Vendor Relationship:	Current Bill/Vendor Statement
					Collateral Contact
		IDENTITY OF HOUSEHOLD MEMBERS
LN	HOUSEHOLD MEMBER’S NAME				DOCUMENTATION
01
02
03
04
05
06

IS ANYONE IN THE HOUSEHOLD VULNERABLE?  Under the age of 6  Age 60 or older  Permanently Disabled

Who__________________________________________ Documentation____________________________________________

RESIDENCE – CHECK TYPE OF DOCUMENTATION OBTAINED

Current Rent Receipt w/Name & Address  Water, Sewage, or Tax Bill  Mortgage Payment Book/Receipts w/Address  Deed

Copy of Lease w/Address  Utility Bill  Homeowners Ins. Policy  Other _______________________________________

INCOME DOCUMENTATION/CALCULATION

Categorically Eligible:  TA  FS  Code A SSI

Comments, resolution activities, income calculation/documentation, verification of emergency for				REGULAR BENEFIT
expedited regular benefit, vendor contract, etc.				(EMERGENCY USE PART B)
Gross Bi-Weekly Income x 2.1666				 SEPARATE HEAT (check one)
Gross Weekly Income x 4.3333				 SEPARATE HEAT (check one)
Gross Weekly Income x 4.3333				 Oil	 Kerosene
				 Oil	 Kerosene
				 LP Gas	 Natural Gas
				 Wood	 Wood Pellets
				 Coal/Corn	 PSC Electric
				 Coal/Corn	 PSC Electric
				 Municipal Electric
				 HEAT INCLUDED IN RENT
				 HEAT INCLUDED IN RENT
				 Payment to Household
				 Payment to Utility
				 Payment to Utility


	TOTAL INCOME $		 TIER I  TIER II	Benefit $ ________________
 Application compared to previous information
 No prior application  No Changes  WMS Inquiry  Changes verified			How:_______________________________________
 Pended	START:	END:		 APPROVED  DENIED
 Pended				 APPROVED  DENIED

CERTIFYING AGENCY

WORKER’S SIGNATURE/DATE

SUPERVISOR’S INITIALS/DATE

CONSENT TO WITHDRAW

I CONSENT TO WITHDRAW MY APPLICATION

SIGN HERE X_________________________________________________

I UNDERSTAND THAT I MAY REAPPLY FOR HEAP BENEFITS AT ANY TIME DURING THE PERIOD THAT HEAP APPLICATIONS ARE BEING ACCEPTED

LDSS-3421 (Rev. 6/11)

NEW YORK STATE HOME ENERGY ASSISTANCE PROGRAM

(HEAP)

APPLICATION INSTRUCTIONS

INSTRUCTIONS FOR COMPLETING THE APPLICATION:

Complete all non shaded areas and answer all questions.

List everyone who lives in your dwelling, even if they are not related to you or contributing financially to your household. You may be required to provide proof of identity for all household members.

Social Security numbers are required for all household members. If any member does not have a Social Security number but has applied for one, write the word “applied” in the Social Security Number box. If you leave this section blank for any

household member, your application will not be processed but will be pended for further information.

List ALL income for all household members. All amounts should be entered as gross income prior to any deductions. You may be required to provide proof of income. Eligibility will be based on your household’s gross monthly income for

the month of application.

Please enter the gross amount of your Social Security and the amounts you pay for Medicare Part B or D. Amounts for Medicare Parts B and D are excluded as income.

Only the interest or dividend portions of bank accounts, CDs, stocks, bonds or other investment income are used to calculate your income. Enter the amount received for the previous twelve (12) months.

Make sure to SIGN and date the application. The application must be signed by the person who has the heating bill in their name, or who pays the bill if it is in someone else’s name. If heat is included in the rent, the primary tenant must

complete and sign the application.

Motor Voter Registration

Please include the Motor Voter form with your application. Complete this form if you are not registered to vote and you want to register. This does not affect your HEAP eligibility or benefit amount.

WHAT WILL I NEED TO APPLY?

New applicants will need to include the following documentation along with your application:

Proof of each household member’s identity

A valid Social Security Number for each household member

Proof of residence

A fuel and/or utility bill if you pay for heat or proof that you pay rent which includes heat

Verification of income for all household members

Please see page 4 of the application instructions for specific types of acceptable documentation. In addition, new applicants will also need to complete an interview; and can choose whether you would like to conduct a phone interview or an in person interview. However, if you do choose a phone interview , please include a working phone number and the best time to contact you for a phone interview on Page 1 of your application.

WHERE TO APPLY:

You must apply in the county in which you currently reside. address stamped at the top of the application or can http://www.otda.ny.gov.

You can apply in person or mail in your application at the find other local certifiers by checking our website at:

LDSS-3421 (Rev. 6/11)

HOW DO I KNOW IF I AM ELIGIBLE?

You will receive a notice to let you know if your application has been approved or denied. If you are approved and you pay for heat, your payment will be sent to your heating fuel vendor. In some cases, your benefit will be paid to your electric company if heat is included in your rent. Your notice will tell you the amount of the benefit, how it will be paid, and how it was calculated. Vendors will not make deliveries until payment is received or until instructed to do so by the local Department of Social Services.

Regular HEAP benefits are intended to be a one-time supplement to your annual energy costs and are not intended to replace your personal payments. You should continue to pay your energy bills.

WHAT IF I HAVE AN EMERGENCY?

HEAP benefits can assist with the following emergencies:

You are out of fuel or have less than ¼ tank of oil, kerosene or propane, or less than a ten (10) day supply of other deliverable heating fuel.

Your natural gas or electric heat has been shut off or is scheduled to be shut off. Applicant owned heating equipment is not working.

If you have a heating emergency and have applied for, but have not received, your regular benefit, you should contact your local Department of Social Services. Whenever possible, regular HEAP benefits are used first to resolve an energy emergency.

DO NOT WAIT UNTIL YOU ARE OUT OF HEATING FUEL OR YOUR GAS/ELECTRIC SERVICE IS OFF TO REQUEST ASSISTANCE. IF YOUR UTILITY SERVICE IS TERMINATED, YOUR UTILITY COMPANY IS NOT REQUIRED TO RESTORE YOUR SERVICE EVEN IF YOU ARE ELIGIBLE FOR A HEAP BENEFIT.

All applications for heating equipment repair or replacement must be in person with full documentation.

Citizen /Alien Information:

In order to receive HEAP you must be a U.S.citizen, Qualified Alien, or U.S non-citizen national. For additional information on what constitutes a Qualified Alien or U.S. non-citizen national, please contact the New York State Office of Temporary and Disability Assistance hotline at 1-800-342-3009 or visit the OTDA website at http://www.otda.ny.gov.

Application Rights:

You have certain rights when filing your HEAP application. You have the right to be told if your application is approved or denied within thirty (30) business days of the date that the HEAP certifier receives your completed and signed application.

The processing time for applications will not begin until program opening even though you may have received an application prior to the program opening date as a part of our outreach effort. Please visit OTDA’s website at

http://www.otda.ny.gov or the OTDA hotline at 1-800-342-3009 for information regarding the date for program opening.

You have the right to request a conference and/or a fair hearing if it has been more than thirty (30) business days since the HEAP certifier received your signed and completed application (or it has been more than thirty business days since program opening if the certifier received your application prior to program opening and you have not been told of the eligibility decision).

If you would like a conference, you should ask for one as soon as possible. At the conference, if it is discovered that a wrong decision was made, or if because of information you provide, the decision is changed; corrective action will be taken.

If you would like a conference, please contact your local Department of Social Services Department listed above. This is only for requesting a conference. It is not how you ask for a fair hearing. If you ask for or have a conference, you are still entitled to a fair hearing.

LDSS-3421 (Rev. 6/11)

You can request a fair hearing from the New York State Office of Temporary and Disability Assistance by:

Calling, toll free:

1-800-342-3334 or by Writing to:

NYS Office of Temporary and Disability Assistance

Office of Administrative Hearings

P.O. Box 1930

Albany, NY 12201-1930.

If you request a fair hearing, NYS will send you a notice of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, friend, or other person, or to represent yourself. At the hearing, your attorney or other representative will have the opportunity to present written and oral evidence, as well as the opportunity to question any persons who appear at the hearing. Also, you have the right to bring witnesses to speak in your favor. You should bring to the hearing any documents that may be helpful in presenting your case.

If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid society or

other legal advocate group. You may locate the nearest Legal Aid society or advocate group by checking the yellow pages under “lawyers”.

You have the right to review your case record. Upon your request, you have the right to free copies of documents that your local Department of Social Services presents into evidence at the fair hearing. Also, upon request, you have the right to free copies of other documents from your case record that you need for your fair hearing. To request such documents or to find out how you may review your case record, contact your local Department of Social Services listed above.

Si necesita alguien que hable español, comuníquese con la línea directa de NYS OTDA al 1-800-342-3009.

Telephone Lifeline Program:

If you qualify to receive HEAP, you also qualify for low cost local telephone service under the Lifeline Program. You can get basic local service for as low as $1.00 per month, plus per call charges and taxes. We will share your name with Verizon so that you can be automatically enrolled in Lifeline, unless you mark the box on the application to decline the release of your information. You may also contact your telephone company to receive a Lifeline application, or for more information on the Lifeline Program. This does not affect your HEAP eligibility or benefit amount.

OTHER PROGRAMS YOU MAY BE ELIGIBLE FOR:

WEATHERIZATION ASSISTANCE

You may also be eligible for weatherization assistance. A list of contacts can be found at: http://nysdhcr.gov/Programs/WeatherizationAssistance/. Your signature on the HEAP application allows a referral to be made to the weatherization assistance program on your behalf.

UTILITY LOW INCOME PROGRAM

You may also be eligible to enroll in you utility company’s low income program. Your signature on the HEAP application allows a referral to be made to your utility company on your behalf.

MY BENEFITS

Additional information about HEAP and other human services programs can be found at MY BENEFITS. You can also conduct a self-screening for eligibility for HEAP and other programs. Please go to https://www.mybenefits.ny.gov for more information.

LDSS-3421 (Rev. 6/11)

TYPES OF ACCEPTABLE DOCUMENTATION

RESIDENCE (Where you now live)
Current rent receipt with name and address of tenant and	Utility bill
landlord or lease with name and address	Mortgage payment books/receipts with address
Water, sewage, or tax bill	Homeowners insurance policy
Deed

IDENTITY

You must provide one or more of the following for each person in your household:

Birth certificate	Social Security card
Baptismal certificate	Driver’s license
School records	Marriage certificate

SOCIAL SECURITY NUMBER

You must provide a valid Social Security Number for each member of your household. If a Social Security Number cannot be validated by the Social Security Administration, you will be required to provide proof of that Social Security Number. To prove a valid Social Security Number, please provide:

Social Security card OR Official correspondence from Social Security Administration

VULNERABILITY

You must provide one of the following for proof of vulnerability for a vulnerable member of your household (children under

6 years of age, adults 60 years of age or older, or anyone with a disability):

Birth certificate	Passport
Copy of benefit check	Driver’s license
Baptismal certificate with date of birth	Written statement of eligibility for benefits
Award letter

HEATING SITUATION

If you pay a fuel or utility bill, bring a copy of your most recent fuel/utility bill or a statement from your vendor.

If you do not pay for heat, bring a current rent receipt with name and address of tenant and landlord, lease with name and address, or statement from your landlord that indicates heat is included in your rent.

INCOME

Pay stubs for the most recent four (4) weeks	COPY OF MOST RECENT CHECK OR AWARD LETTER
If self-employed, business records for the most recent	FOR THE FOLLOWING:
three (3) months or your filed federal tax return for the current	Social Security/Supplemental Security Income (SSI)
year, including all applicable schedules or prior tax year if	Veteran’s Benefits
you have not yet filed for the current year	Pensions
Rental income receipts for previous 12 months	Worker’s Compensation/Disability
Child support or alimony checks	Verification of Unemployment Insurance Benefit amount
Bankbook/dividend or interest statement	Educational Grants/Loans
Statement from roomer/boarder
RESOURCES (For emergency benefit applications only)
Cash Checking and/or savings account balances	IRA accounts
Stocks/bonds	Lump sums from sale of property or insurance
Time Deposit Certificates	settlements.

Applications for Heating Equipment Repair and Replacement require additional documentation. If you are applying for this component, you will be given a separate list of documentation you need to provide.

NYS Agency-Based Voter Registration Form

Important!

“If you are not registered to vote where you live now,

would you like to apply to register here today?”

Applying to register or declining to register to vote will

□

not affect the amount of assistance that you will be

YES

(If you check yes, please complete VOTER REGISTRATION

provided by this agency.

□

APPLICATION at bottom of page)

NO because I choose not to register OR

□ I am already registered at my current address OR

If you would like help filling out

the voter registration application

□ I asked for and received a mail registration form.

form, we will help you. The decision whether to seek or accept help

is yours. You may fill out the application form in private.

If you do not check any box, you will be considered to have

decided not to register to vote at this time.

Información en español: si le interesa obtener este formulario en

español, llame al 1-800-367-8683

_____/______/______

(Signature)

(Date)

(Please Print Name)

VOTER REGISTRATION APPLICATION (instructions on back)

NVRA-05 (01/2011)

□ Yes, I need an application for an Absentee Ballot

Please print or type in blue or black ink □ Yes, I would like to be an Election Day worker

Are you a U. S. citizen?

Will you be 18 years old on or before election day?

For Board use only!

Yes □

No □

Yes □

No □

If you answered NO, do not complete this form unless

If you answered NO, do not complete this form.

you will be 18 by the end of the year.

Last Name

First Name

Middle Initial

Suffix

Address where you live (do not give P.O. address)

Apt. No.

City/Town/Village

Zip Code

County

Address where you get your mail (if different from above)

P.O. Box, star route, etc.

Post Office

Zip Code

Date of Birth

Sex (circle)

Home Tel. Number (optional)

ID Number—Check the applicable box and provide your

number:

□ New York DMV number __ __ __ __ __ __ __ __ __

The last year you voted

Your Address was (give house number, street and city)

If you do not have a New York DMV number, please

provide:

□ Last four digits of your

In county/state

Under the Name (if different from your name now)

Social Security Number __ __

__ __

□ I do not have a New York Driver’s license number

Choose a party -- Check one box only

AFFIDAVIT: I swear or affirm that

□ Democratic Party

I am a citizen of the United States.

I will have lived in the county, city or village for at least 30 days before the election.

□ Republican Party

I will meet all requirements to register to vote in New York State.

□ Conservative Party

This is my signature or mark on the line below.

The above information is true, I understand that if it is not true, I can be convicted and

□ Working Families Party

fined up to $5,000 and/or jailed for up to four years.

□ Independence Party

□ Green Party

□ Other (write in)

→

□ I do not wish to enroll in a party

(Signature or Mark in Ink)

(Date)

(Optional) Register to donate your organs and tissues

Last Name

First Name

Middle Initial

Suffix

Address

Apt Number

Zip Code

City

Birth Date

Sex □ M

□ F

Eye Color

Height

Ft.

In.

By signing below, you certify that you are:

18 years of age or older

Consent to donate all of your organs and tissues for transplantation, research, or both;

Authorizing the Board of Elections to provide your name and identifying information to DOH for enrollment in the Registry;

And authorizing DOH to allow access to this information to federally regulated organ procurement organizations and NYS-licensed tissue and eye banks and hospitals upon your death.

Sign

Date

Qualifications for Registration

You Can Use This Form To: register to vote in New York State;

change your name and/or address, if there is a change since you last voted;

enroll in a political party or change your enrollment. To Register You Must:

be a U.S. citizen;

be 18 years old by December 31 of the year in which you file this form (note: You must be 18 years old by the date of the general, primary, or other election in which you want to vote.);

be a resident of the County, or of the City of New York at least 30 days before an election;

not be in jail or on parole for a felony conviction; and not claim the right to vote elsewhere.

Important!

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:

New York State Board of Elections, 40 Steuben Street,

Albany, New York 12207-2109

Telephone: 1-800-469-6872;

TDD/TTY users contact the New York State Relay at 711;

or visit our web site - www.elections.state.ny.us

Your decision to register will remain confidential and will be used only for voter registration purposes. Anyone not choosing to register to vote and/or information regarding the office to which the application was submitted will remain confidential, to be used only for voter regis- tration purposes.

Verifying your identity

We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID number), or the last four digits of your social security number, which you will fill in Box 9.

If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement, pay- check, government check or some other government document that shows your name and address. You may include a copy of one of those types of ID with this form.

If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.

To complete this form:

It is a crime to procure a false registration or to furnish false information to the Board of Elections.

Box 9: You must make one selection. For questions refer to Verifying your identity above.

Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?). If you voted before under a different name, put down that name. If not, write “Same”.

Box 11: Check one box only. To vote in a primary election, you must be enrolled in one of these listed parties — Except the Independence Party, which permits non-enrolled voters to participate in certain primary elections.

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