The LDSS-5025 form, updated in July 2015, is a crucial document for individuals receiving benefits under the New York State Supplement Program (SSP), but not for those receiving federal Supplemental Security Income (SSI) benefits, who must contact the Social Security Administration directly. This form facilitates the enrollment into Direct Deposit, offering a more secure and expedient method for beneficiaries to access their funds. It is explicitly designed for SSP beneficiaries wishing to have their benefits deposited directly into their bank accounts, necessitating the completion of both sections of the form. Completion and submission require attention to detail, as any missing information will result in the form being returned. The document outlines clear instructions for its submission, either by mail to a designated address in Albany, NY, by fax, or by emailing a hand-signed version. It also provides contact information for the SSP Customer Support Center, ensuring that applicants have the necessary support throughout the process. Furthermore, it mandates the inclusion of specific personal and financial details, including a certification of entitlement to SSP benefits, and an authorization for the SSP to deposit benefits directly into the named financial institution's account. The financial institution's part of the form confirms its ability to handle such transactions, aligning with New York's regulatory standards for immediate availability of deposited funds to the beneficiary. This process emphasizes security, efficiency, and compliance, aiming to streamline the benefits distribution for SSP recipients.
| Question | Answer |
|---|---|
| Form Name | Form Ldss 5025 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ldss, form 5025, otda forms, New_York |
NYS OTDA State Supplement Program (SSP)
Direct Deposit Enrollment Form
Directions:
∙To be completed by individuals who receive only SSP benefits. Individuals receiving federal SSI benefits need to contact SSA.
∙Complete this form ONLY if you wish to enroll in Direct Deposit. BOTH sections must be completed.
∙Return the completed form to: NYS OTDA State Supplement Program, PO Box 1740, Albany NY 12201; or
by FAX to:
∙Please contact the SSP Customer Support Center at
The following information must be provided. If ANY information is missing, the form will be returned for completion.
Recipient Name ___________________________________________ |
Daytime Phone Number (____) |
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LAST |
FIRST |
MI |
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Recipient Mailing Address __________________________________________________________ |
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City ____________________________________________ |
State ____________ Zip Code _________ |
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Date of Birth (MM/DD/YYYY) ____ / ____ / ________ |
Last Four Numbers of SSN XXX |
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I certify that I am entitled to the benefits associated with the NY State Supplement Program (SSP). In signing this form, I authorize the SSP to send my benefits to the financial institution named below to be deposited into the account indicated by the financial institution. This authorization will remain in force until I provide written notice of termination.
Print Name_________________________________ Signature __________________________________ Date ____________
ACCOUNT INFORMATION
Please take this form to your bank or credit union for the completion of the information below. You may also choose to attach a voided preprinted (not starter) check containing your name and address or an account deposit form containing your name and address.
This CANNOT be a Trust Account to benefit another OR a Foreign Financial Institution Account
Account Information:
Checking
Savings
Name on Account: __________________________________ Relationship to Recipient: ___________________________________
Bank Information: Name of Financial Institution (bank or credit union): _________________________________________________
Address ___________________________________________ City___________________________ State________ Zip__________
Account Number __________________________________ Routing Transit Number_______________________________________
As representative of the
_______________________________________ |
________________________________________ |
_______________ |
Representative Signature |
Representative Printed Name |
Date |