Form Preview Example

LDSS-2921 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

CENTER/

APPLICATION DATE

UNIT ID

WORKER ID

CASE

SERV.

CASE NUMBER

REGISTRY NUMBER

VERS

DISTRICT

SUFFIX

SNAP

SPONSORED

DEGREE RECEIVED



RCA/RMA REFERRAL

ADJUSTED

ENTRY/STATUS

CITIZENSHIP

YES

MONTH

DAY

YEAR

YES

PAGE 3

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 7 – RACE/ETHNICITY – Providing this information is

ENTER APPROPRIATE CODES

voluntary. It will not affect the eligibility of the persons applying or the

level of benefits received. The reason for requesting this information is

to ensure that program benefits are distributed without regard to race,

CLIENT

color, or national origin.

IDENTIFICATION

HISPANIC OR LATINO

NUMBER

NATIVE AMERICAN OR ALASKAN NATIVE

ASIAN

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN OR PACIFIC ISLANDER

WHITE

REL

SSN

SFUI



UNKNOWN (MA ONLY)

ENTER Y (YES) OR N (NO) FOR HISPANIC OR LATINO

ENTER Y (YES) OR N (NO) FOR EACH RACE

ANTICIPATED FUTURE ACTION

CASE TYPE

RELATED CASE NUMBERS

CONSIDER

REQUESTED

DOCUMENTATION

IN FILE

LINE NO.

CODE

DATE

 Relationship

Photo ID

 Filing Unit

Birth Verification

 Legally Responsible Relative

Marriage License

SERVICE ELIGIBILITY PROCESS CODE

 Single Economic Unit

Social Security Card

SFUI

CODE

SFUI

CODE

 SNAP Household Composition

Code 9 Resolution

 SNAP Aged/Disabled Individual

SFUI

CODE

SFUI

CODE

 Photo ID

Immigration Status

NEEDED

REFERRALS

COMPLETED

Legal

 AFIS (PA Only)

Multi-Suffix/Co-op Case Notice (Single

 CBIC/PIN

Economic Unit Questionnaire)

Services

 RFI/OCA

SSA

 Health Insurance

NYSoH

Chronic Care/SSI-Related

MA-Only

Medicare Savings Program

LDSS-2921 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

PAGE 4

Please read this entire page carefully before completing it. If you have questions, see the instruction book (PUB-1301 Statewide) or talk to your social services district.

SECTION 8 – CITIZENSHIP/NON-CITIZEN WITH SATISFACTORY IMMIGRATION STATUS

SECTION 9 – CERTIFICATION

LIST EVERYONE WHO IS APPLYING OR WHO IS REQUIRED TO APPLY.

Some social services programs require that you certify that you are a United States citizen, Native American or

You have to fill out Sections 8 and 9 if you are:

national of the U.S., or a non-citizen with satisfactory immigration status. Other programs do not.

You MUST sign the Certification below only if you are a United States citizen, Native American or national of the

• Applying for Child Care Assistance only, but you need to fill out the information only for the

United States, or a non-citizen with satisfactory immigration status, and you are applying for:

children who would be receiving Child Care Services.

• Public Assistance (where there are children in the household or a member of the household is pregnant),

• Applying for Foster Care only, but you need to fill out the information only for the children who

would be receiving Foster Care.

• The Supplemental Nutrition Assistance Program, or

• Applying for other Services under certain circumstances.

• Medicaid (except if the applicant is pregnant), or

• Child Care Assistance (certification is needed for the children only), or

• Foster Care (certification is needed for the children only), or

• Other Services under certain circumstances;

• Emergency Payment Assistance

An adult household member or authorized representative may sign for all household members. Example: A

parent without a satisfactory non-citizen status may sign for their child with a satisfactory non-citizen status.

NEEDED

REFERRALS

COMPLETED

Systematic Alien Verification for Entitlements (SAVE)

An application for SNAP must list all persons living in the SNAP household. An application for PA must list all children for whom you are applying,

SIGN* AND DATE THE BOX BELOW FOR EACH APPLICANT.

their siblings, and all parents of those children who live together. If you do not check whether a listed person is a United States citizen, national of

In the case of an applying non-citizen with a satisfactory immigration

the U.S. or an non-citizen with a satisfactory immigration status, or provide an U.S. Citizenship and Immigration Services (USCIS) number (Alien

status, check the program(s) for which each applying non-citizen has

Registration Number) or a non-citizen number (if applicable), that person will not be given assistance and the remaining members of the

satisfactory immigration status. (See the instruction book, Pub-1301

Statewide.)

household will receive reduced benefits. If you are a Native American, check citizen/national.

Check either "CITIZEN / NATIONAL" or

USCIS NUMBER (ALIEN REGISTRATION

FIRST NAME

LAST NAME

"NON-CITIZEN"

NUMBER) OR NON-CITIZEN NUMBER

DATE

CERTIFICATION

(If Applicable)

for each person.

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

฀

CITIZEN/

฀

Sign Name

NATIONAL

NON-CITIZEN

By checking a box above and by signing the certification in Section 9, I hereby certify, under penalty of perjury, that I, and/or the person(s) for whom I am signing, am a United States citizen, Native American

or national of the United States, or a non-citizen with satisfactory immigration status.

I understand that signing this Certification may result in information about applying members of my household being submitted to the United States Citizenship and Immigration Services for verification of non-citizen status, if applicable.

The use or disclosure of the information above is restricted to persons and organizations directly connected with the verification of citizenship status, and the administration or enforcement of the provisions of the Public Assistance, Supplemental Nutrition Assistance, Medicaid, Child Care Assistance, Foster Care and Services Programs.

*A person who wishes to sign the Certification but cannot write may make an "X" on the line in front of a witness. The witness must sign below.

I witnessed the marks made in lines: _____,______,_______,______,_____,_____ Signature of witness: _____________________________________

Date Signed: ____________________

PAGE 5

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 10 – INFORMATION REGARDING REFERRAL TO THE CHILD SUPPORT ENFORCEMENT UNIT

If you are applying only for child care assistance, you are not required to pursue child support and do not have to fill out this section.

If you

REQUESTED

DOCUMENTATION

IN FILE

are applying for Medicaid in addition to Public Assistance or the Supplemental Nutrition Assistance Program, you may have to help us obtain

Acknowledgment of Parentage

medical support for yourself and your applying children. Answer the following questions to determine if you need to complete this section.

or Paternity

Include yourself, as appropriate:

Child Support Order

Good Cause Form (LDSS-4279)

1. Are you applying for an individual under the age of 21 who was born out of wedlock and for whom legal parentage has not been

IV-D Attestation (LDSS-4281)

Death Certificate

established? ฀ Yes

฀ No

Divorce Decree

Are you applying for an individual under the age of 21 who has an absent parent (noncustodial parent)? ฀ Yes

฀ No

VA Benefits

You do not need to complete this section if you answered “No” to both of these questions. Go to Section 11.

Order of

Filiation/Paternity/Parentage

You must complete this section if you answered “Yes” to either or both of these questions. Provide the names of all individuals under

Birth Certificate

NEEDED

REFERRALS

COMPLETED

the age of 21 for whom you are applying and any information you currently have about those individuals’ noncustodial parents or alleged

CTHP

parents.

CAP

Are you under the age of 21? ฀ Yes

฀ No

Referral for Child Support

Services (LDSS-5145)

If you answered “Yes” to this question, provide the information for your noncustodial parent(s) or alleged parent(s).

Parentage/Paternity

CONSIDER

As a condition of obtaining assistance, you are required to assign certain rights related to support, as described in the Notices, Assignments,



Health Insurance of Non-



Child Health Plus

Authorizations, and Consents section at the end of this application. You will be provided with the LDSS-5145 form, “Referral for Child Support

custodial Parent/Absent



TASA

Spouse

Services,” to complete and return to the Child Support Enforcement Unit. Except in situations of domestic violence or other good cause, as a



condition of obtaining assistance, you are required to cooperate with the Child Support Enforcement Unit to locate any noncustodial parent or

Petition to Family Court

SSI/SSA

alleged parent; establish legal parentage for each individual under the age of 21 born out of wedlock; and establish, modify, and/or enforce

orders of support. You also will be provided with the LDSS-4279 form, “Notice of Responsibilities and Rights for Support,” which explains

your responsibilities and your rights if you do not cooperate with the Child Support Enforcement Unit.

NONCUSTODIAL PARENT

NAME OF INDIVIDUAL UNDER AGE 21

NONCUSTODIAL PARENT OR ALLEGED PARENT’S NAME AND ADDRESS

OR ALLEGED PARENT’S

NONCUSTODIAL PARENT OR

DATE OF BIRTH

ALLEGED PARENT’S

SOCIAL SECURITY NUMBER

MONTH

DAY

YEAR

LDSS-2921 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

PAGE 6

SECTION 11 – TAX FILING/DEPENDENT STATUS - Please select the tax status for each individual living in the household.

TAX STATUS

FIRST NAME

MIDDLE

LAST NAME

SINGLE

MARRIED

HEAD OF

QUALFIYING

DEPENDENT

WILL NOT BE

INITIAL

FILING

HOUSEHOLD

WIDOW(ER)

AND WILL BE

FILING TAXES

JOINTLY

SINGLE

(WITH

WITH

FILING TAXES

QUALIFYING

DEPENDENT

INDIVIDUAL)

CHILD

Tax dependents not living in the household. Please list any tax dependents who do not live with you and are claimed by you or anyone in your household. If you do not file taxes, you

can skip this question.

NAME OF TAX DEPENDENT

NAME OF TAX FILER

FIRST NAME

MIDDLE INITIAL

LAST NAME

FIRST NAME

MIDDLE INITIAL

LAST NAME

SECTION 12 – ABSENT/DECEASED SPOUSE INFORMATION – If the spouse of anyone applying lives someplace else or is deceased, please indicate below.

NAME OF PERSON APPLYING

NAME OF SPOUSE

DATE OF SPOUSE’S BIRTH DATE OF SPOUSE’S DEATH, SPOUSE’S SOCIAL SECURITY NUMBER IF APPLICABLE

SPOUSE’S ADDRESS, IF APPLICABLE

CITY

COUNTY

STATE

ZIP CODE

SECTION 13 – ABSENT CHILD INFORMATION – If anyone applying has a child under the age of 21 living someplace else, please indicate below.

ADDRESS OF CHILD (STREET, CITY,

LEGAL PARENTAGE ESTABLISHED?

DO YOU PAY CHILD SUPPORT?

NAME OF PERSON APPLYING

NAME OF ABSENT CHILD

DATE OF BIRTH

COUNTY, STATE, AND ZIP CODE)

Yes

SECTION 14 – TEEN PARENT INFORMATION

TEEN PARENT

TEEN PARENT CHILDREN

Is there a parent under the age of 18 (“teen parent”) in the household? ฀ Yes

฀ No

LN NO.

Marital Status

LN NO.

__________________

High School Diploma/High School Equivalent?

Name ________________________________________________

LN NO. _____________________

LN NO.

Marital Status

High School Diploma/High School Equivalent?

Does the teen parent’s child live in the household? ฀ Yes

฀ No

Name of teen parent’s child _______________________________________________

PAGE 7

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 15 – INCOME INFORMATION:

Indicate if you or anyone who lives with you receives money from:

YES

WHO

AMOUNT/VALUE &

WHO

AMOUNT/VALUE &

INCOME

FREQUENCY

Unemployment Insurance Benefits

SOURCE

No.

CODE

AMOUNT

PERIOD

Supplemental Security Income (SSI) Benefits (State and Federal

Total)

Social Security Disability (SSD) Benefits

Social Security Dependent Benefits

Social Security Survivor’s Benefits

Social Security Retirement Benefits

Railroad Retirement Benefits

Retirement Benefits (Pensions)

Dividends/Interest from Stocks, Bonds, Savings, etc.

Workers’ Compensation

NYS Disability Benefits

Veteran’s Pension/Benefits/Aid and Attendance

Public Assistance Grant

GI Dependency Allotments

Education Grants or Loans

Contributions/Gifts (Received)

Foster Care Payments (Received)

Child Support Payments (Received)

CONSIDER

Received From:________________________________________18



Child Support Disregard/Pass-Through

฀ Explained

฀ Budgeted

Spousal Support (Received)



SNAP Aged/Disabled Indicator

Private Disability Insurance - Health/Accident Insurance Policy



Disability Review

Income



Reception and Placement Grant (SNAP

No-Fault Insurance Benefits

Only)

Union Benefits (including Strike Benefits)



Refugee Matching Grant

Loans, Other than Education (Received)

Income from a Trust (including income you are currently entitled to

receive, or were entitled to receive in the past, that has not been

distributed)

Training Allotments/Stipends

Rental Income (Received)

Boarders/Lodgers Income (Received)

Other

Income

(Please

Specify)

LDSS-2921 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

PAGE 8

Deductions: Certain types of Medicaid budgeting allow
applicants/recipients to reduce their countable income with deductions
that they take on their federal taxes. These are specific expenses that					AMOUNT/VALUE &		AMOUNT/VALUE &
the Internal Revenue Service (IRS) allows people to deduct to reduce		YES	NO	WHO	AMOUNT/VALUE &	WHO	AMOUNT/VALUE &
		YES	NO	WHO	FREQUENCY	WHO	FREQUENCY
					FREQUENCY		FREQUENCY
their taxable income. Only record deductions here if you will claim them
on the current year’s tax return.

Educator expenses	1

Individual Retirement Account (IRA) deduction	2

Student loan interest deduction	3

Tuition and fees	4

Certain business expenses (reservists, artists, fee-based government
officials)	5
Health savings account deduction	6

Job-related moving expenses	7

Deductible part of self-employment (S/E) tax	8

S/E, SIMPLE & qualified plans	9

S/E health insurance deduction	10

Penalty on early withdrawal of savings	11

Alimony paid	12

Domestic production activities deduction	13

Additional adjustments added on line 36 (IRS Form 1040 only)	14

Archer MSA deduction	15

Other Adjustment
(Please Specify)

SECTION 16 – STEPPARENT/NON-CITIZEN WITH SATISFACTORY

IMMIGRATION STATUS SPONSOR INFORMATION

Answer all questions listed below.

YES

WHO?

Does the stepparent of any children who live with you have any resources or receive income of any kind?

Is anyone in your household a non-citizen with satisfactory immigration status who was sponsored for admission into the U.S.?

NAME OF SPONSOR:

PHONE NO.:

NEEDED

REFERRAL

COMPLETED

UIB

ADDRESS:

PAGE 9

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 17 – EMPLOYMENT INFORMATION

I am currently:

฀ employed

฀ self-employed

฀ unemployed

Gross Income $ ________________

Hours Worked Monthly _________________

REQUESTED

DOCUMENTATION

IN FILE

(Include wages, salary, overtime pay,

CINTRAK/RFI/IRCS

commissions, and tips)

1099

Paid: ฀ Weekly

฀ Biweekly

฀ Monthly

Day of the week paid:

Employment Verification

Employer’s Name and Address:

Income Tax Return

______________________________________________

Phone No. __________________

Self-Employment Worksheet

______________________________________________

Wage Stubs

Is anyone else who lives with you currently:

฀ employed

฀ self-employed

Work Registration Form

Dependent/Child Care Form/Statement

Who: _________________________________________________

Approval of Informal Child Care Provider

Gross Income $ ________________

Hours Worked Monthly _________________

Paid: ฀ Weekly

฀ Biweekly

฀ Monthly

Day of the week paid:

Employer’s Name and Address:

______________________________________________

Phone No. __________________

NEEDED

REFERRALS

COMPLETED

CONSIDER

 Limited English Proficiency

______________________________________________

CAP

 Earned Income Tax Credit (see PUB-4786)

Disability

 Explaining Periodic Reporting Requirements

Employment

 Net Loss of Cash Income

Is health insurance available through your employer?

฀ Yes

฀ No

TPHI/COBRA

 P.A.S.S. Income Amount and Sources

Does anyone who lives with you have health insurance with an employer?

฀ Yes

฀ No

UIB



Employment Sanctions

Who: _________________________________________



Temporary Employment

Workers’ Compensation



Disability Review

Name of Insurance Company: _________________________________________________________

Drug/Alcohol

 Individual Development Account (IDA)

Domestic Violence



Voluntary Quit

Do you or anyone who lives with you have a child or dependent care

฀ Yes

฀ No

Refugee Cash Assistance

expenses due to employment?

Who: _________________________________________

Do you or anyone who lives with you have other employment-related

฀ Yes

฀ No

expenses?

Who: _________________________________________

LDSS-2921 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION		PAGE 10

If not employed, when was the last time you or anyone who lives with you worked?
Who: _________________________________________		When: __________________________
Where: __________________________________________________________________________					6
Why did you (or they) stop working? ___________________________________________________
Did you or anyone living with you file for unemployment?		฀ Yes	฀ No
If yes, who? _______________________	When?: ________________
Status of filing: ฀ Approved ฀ Denied ฀ Pending

Are you or is anyone who lives with you participating in a strike?			฀ Yes	฀ No
Who: _________________________________________					7
Who: _________________________________________
When the strike began: ___________________________

Are you or is anyone who lives with you a migrant or seasonal farm			฀ Yes	฀ No
worker?			฀ Yes	฀ No
worker?
Who: _________________________________________					8

Do you or any other adult who lives with you have any medical conditions that limit the ability to work or the type of work that can be performed? ฀ Yes ฀ No

Who: ____________________________________

Describe Limitations: _____________________________________________________________

_____________________________________________________________

			9

Could you accept a job today?	฀ Yes	฀ No	10
Could you accept a job today?
If not, why? ________________________________________________________________________

What type of work would you like to do? _________________________________________
_________________________________________________________________________________			11

CHILD/DEPENDENT CARE EXPENSES

Who Pays	Amount	Name	Age	Care Provider
	$
	$
	$
	$
	$
	$
	$
	$

PAGE 11

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 18 – EDUCATION/TRAINING

What is your highest level of education completed?

__ Less than high school diploma

REQUESTED

DOCUMENTATION

IN FILE

NEEDED

REFERRALS

COMPLETED

If so, last grade completed? ______

School Attendance Verification

Supportive Services

__ Completion of an Individualized Education Plan (IEP)

(LDSS-3708)

__ High school diploma or General Equivalency Diploma (GED) or Test Assessing

Educational Grant Worksheet

Secondary Completion (TASC™)

Child Care Statement

__ Associate’s Degree (2-year college degree)

__ Bachelor’s Degree (4-year college degree) or higher

Does anyone else in the household have a high

฀ Yes

฀ No

school diploma, General Equivalency Diploma

(GED) or Test Assessing Secondary Completion

(TASC™), or higher level of education?

If yes, who: _______________

CONSIDER

YES

Does anyone 18 through 49 who is attending college half-time or more

฀

Degree attained: _________________

meet the SNAP student eligibility requirement?

Does anyone pay for child or dependent care to attend school or

฀

Date completed: _________________

training?

Is there a 16-19 year-old parent who does not have a high school or

฀

Indicate if you or anyone who lives with you who is applying for or getting assistance:

equivalency diploma and who is not attending school?

Is anyone in training?

฀

฀ Yes

฀ No

Is or has been in any training program?

Are any other supportive services appropriate?

฀

Who

Are there any training related expenses?

฀

Where

Program

Dates attended ________________________________

Dates completed _______________________________

Is 16 years of age or older and is attending school or

฀ Yes

฀ No

college?

Who

Where

Is under 16 years of age and is attending school?

฀ Yes

฀ No

Who

School

Who

School

LDSS-2921 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

PAGE 12

SECTION 19 – RESOURCES INFORMATION

Indicate if you or anyone who lives with you who is applying:

YES

WHO

AMOUNT/VALUE

WHO

AMOUNT/VALUE

NEEDED

REFERRAL

COMPLETED

Has cash available

Legal

Has a checking account(s)

Resource

Has a savings account(s) or certificate(s) of deposit

Has a credit union account(s)

Has life insurance

Has title or registration to a motor vehicle(s)

LIFE INSURANCE

or other vehicle(s):

FACE AMOUNT

CASH VALUE

Year ________ Make/Model ____________________________

Other______________________________________________ 6

Has stocks, bonds, certificates or mutual funds

Has savings bonds

Has an IRA, Keogh, 401(k) or deferred compensation account(s)

Has an irrevocable burial trust

Has a burial fund

Has a burial space

REQUESTED

DOCUMENTATION

IN FILE

Resource

Checklist

Has their own home

Has real estate, including income-producing and

Market Value

DMV Clearance

non-income-producing property

Bank Statement

Is eligible for an income tax refund

Has an annuity

Assignment

of Proceeds

Car/Vehicle

Title

Is the beneficiary of a trust

Car/Vehicle

Registration

Expects to receive a trust fund, lawsuit settlement, inheritance or

(Older Models)

income from any other sources

Bank Clearance

Has an “in trust” account(s)

RFI/OCA

Has a safe deposit box(es)

1099

Has resources other than those listed above

Has anyone (including your spouse, even if not applying or living

CONSIDER

with you) given away any cash, or sold/transferred any real



Children’s Resources

estate, income or personal property in the past 36 months?



Lump Sum

Has anyone (including your spouse, even if not applying or living



Boats, Campers, Snowmobiles

with you) ever created a trust in the past or transferred any assets



Individual Development Account (IDA)

to a trust within the past 60 months?



Exempt Vehicles

If yes, when? _______________________________________23

VEHICLE INFORMATION

YR.	MAKE	MODEL	OWNER’S NAME	AMOUNT OWED	NADA VALUE	EXEMPT		LIEN HOLDER	ACCOUNT NO.
						YES*	NO

				$	$

$	$

*IF EXEMPT, WHY?

PAGE 13

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 20 – MEDICAL INFORMATION

REQUESTED

DOCUMENTATION

IN FILE

Pregnancy Statement

Indicate if you or anyone who lives with you who is applying:

YES

IF YES, WHO

Med/Psych Statement

Has any medical bills or medically-related expenses

Drug/Alcohol Screening (LDSS-4571)

Is on Medicaid with a spend-down

Drug/Alcohol Statement

Paid or Unpaid Medical Bills

POLICY NO.:

Has health or hospital/accident insurance (including insurance

AMOUNT:

SSI Application Verification (PA ONLY)

from employer)

FREQUENCY OF PAYMENT:

CONSIDER



AD/SSI Related

Has health insurance available through an employer

INSURANCE COMPANY NAME:



SNAP Aged/Disabled Indicator

WHO IS COVERED:



SNAP Medical Deduction

Has Medicare (red, white, and blue card)



TPHI Reimbursement

EFFECTIVE DATE:



Buy-In Eligibility

Has a health attendant/home health aide



Kreiger (LDSS-3664)



Domestic Violence

Is blind, sick or disabled

Is the answer to question 7 in this section consistent



SSI Referral

with Section 17 asking if the applicant or any other adult



Is a child with a developmental disability

Earned Income Credit

who lives in the household have any medical conditions

that limit their ability to work or the type of work that

NEEDED

REFERRALS

COMPLETED

they can perform?

SSI (D-CAP)

Is in a hospital, nursing home or other medical institution

Disability Interview (LDSS-1151)

Has paid or unpaid medical bills within 3 months preceding

Medical Report (LDSS-486, 486t)

the month of this application

Disability Report

Is or was drug or alcohol dependent

Needs home care/personal care

TPHI

Is on SSI or has ever applied for SSI

ACCES-VR

CTHP

Is pregnant

Family Planning

If pregnant, due date: _____________________________

Expected number of births: _________________________

SSA (RSDI)

Receives treatment from a drug abuse or alcohol treatment

Veteran’s Benefits

program

Veteran’s Counseling

Has not been able to work for at least 12 months because of

Child Health Plus

a disability or illness

COBRA Eligibility

Has daily activity limited because of a disability or illness that

Nurse’s Aide Service

has lasted or will last at least 12 months

Home Care

Has been in a car accident or work-related accident in the past two

NYSoH

years

MA-Only (DOH-4220)

Has had a government agency (public program) besides Medicaid

SSI-Related/Chronic Care

or Medicare pay any of your medical bills

(DOH-4220 with Supplement A)

If yes, what agency _____________________

LDSS-4526 or local equivalent

Will billing any other health insurance cause harm to your physical

or emotional health or safety, and/or will it interfere with the privacy

and confidentiality of your application for or receipt of Medicaid?

LDSS-2921 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

PAGE 14

RETROACTIVE

MEDICAID

WHO

DATE

RECURRING

MEDICAL

EXPENSES

WHO

AMOUNT $


MEDICAL BILLS:	฀ YES	฀ NO


	TPHI: ฀ YES		฀ NO
	TPHI: ฀ YES		฀ NO

HEALTH PLAN SELECTION

Most people enrolled in Medicaid are required to join a managed care health plan unless they are in an exempt category. Use this section to choose a health plan. If you do not know what health plans are available, ask your worker or call 1-800-505-5678.

							Primary Care Provider (PCP) or
Name of Plan You Are Enrolling In	Last Name	First Name	Date of Birth	Sex	ID# (from Medicaid Card	Social Security #	Health	Name and ID# of OB/GYN
			Date of Birth	Sex	ID# (from Medicaid Card	Social Security #	Health	Name and ID# of OB/GYN
			mm/dd/yy	M/F	if you have one)	(optional if pregnant)	Center (check box if current	(check box if current provider)
			mm/dd/yy	M/F	if you have one)	(optional if pregnant)	Center (check box if current	(check box if current provider)
							provider)
							฀	฀
							฀	฀
							฀	฀
							฀	฀

SECTION 21 – SHELTER

WHAT IS YOUR LANDLORD’S NAME?

______________________________________________________________________

WHAT IS YOUR LANDLORD’S ADDRESS?

_______________________________________________________________________

WHAT IS YOUR LANDLORD’S PHONE NUMBER?

() _________________________________________________________

	YES NO	IF YES,
	YES NO	AMOUNT
		AMOUNT

Do you or anyone who lives with you have a rent, mortgage or	$
other shelter expense?

Do you or anyone who lives with you have a heat bill separate	$

from your rent or other shelter expense?


	SHELTER	MONTHLY
	COSTS	ACTUAL COST

A. Room and Board

B. Rent

C. Trailer Lot Rent

D. Mortgage Payment

1.	Principal
2.	Interest
3.	Property Tax
	(including
	School Tax)
4.	Homeowner’s
	Insurance
	(incl. Fire
	Insurance)
5.	Taxes
	Included
	in Mortgage
	(Escrow
	Payment)
6.	Assessments
	(Sewer, etc.)

E. Total Mortgage

Payment (Line 1-6)

TOTAL

(Lines A - E)

REQUESTED

DOCUMENTATION

IN FILE

Landlord Statement

Rent Receipt

Tenant of Record

Customer of Record

Voluntary Restrict

Mandatory Restrict

Subsidized Housing

Mortgage/Title Search

Section 8 Lease or Statement from

Section 8 Office

Property Lien

Shelter/Utility Repayment Agreement

CONSIDER

Utility and/or Fuel Restrict

Utility Guarantee

HEAP

Subsidized Housing May Show Total Rent, NOT Client Amount

Foster Care-Related Additional Allowances

SNAP Household Composition Rules

SNAP Aged/Disabled Indicator

Real Property Tax Credit

AIDS/HIV Emergency Shelter Allowance

Property Lien

If Shelter Expenses/Living Quarters Are Shared by More than One Household

PAGE 15

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 21 – SHELTER (CONT.)

Do you or anyone who lives with you have the following

YES

IF YES,

expenses separate from your rent or other shelter expense?

AMOUNT

Electricity (for needs other than heat; example: lights, cooking,

hot water, etc.)

Natural Gas (for needs other than heat; example: cooking, hot

water, etc.)

IN WHOSE NAME IS

THE BILL?

MONTHLY

NAME OF

ACCOUNT

(CUSTOMER OF

WHO IS THE TENANT

Water

EXPENSES

ACTUAL COST

DEALER

NUMBER

RECORD)

OF RECORD?

A. Heat*

B. Electricity (for cooking, lights, hot water)

Air Conditioning

C. Gas (for cooking, hot water)

Propane (for needs other than heat)

D. Liquid Propane Gas

E. Other Utilities or Expenses

Sewer

F. Air Conditioning

G. Utility Installation Fees

Trash

H. Sewer

I. Trash

Other Utilities and Expenses

J. Water

Specify __________________

Do you live in public housing?

Do you live in Section 8, HUD, or other subsidized housing? 10

*Check Primary Heat Type:

Do you live in a drug/alcohol treatment facility?

฀ Natural Gas

฀ Oil

฀ PSC Electric

฀ Coal

฀ Other ________________________

฀ Kerosene

฀ Propane

฀ Municipal Electric

฀ Wood

ADDITIONAL INFORMATION

SECTION 22 – OTHER EXPENSES

Indicate if you or anyone who lives with you who is applying:

YES

IF YES, AMOUNT

HOW OFTEN

LEGALLY

CHILD IN

PAID

OBLIGATED

SNAP HH

Pays child support

YES

Pays spousal support

Pays for child care

Pays for dependent care

Pays tuition, fees, or other educational expenses

Has additional expenses (Example: car payment, car

insurance payment, credit card payments, other loan

payments, etc.)

Specify: _______________________________

Do you or anyone who lives with you who is applying

฀ YES

฀ NO

owe at least four months of support for a child under the

age of 21?

LDSS-2921 Statewide (Rev. 07/20)			DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION					PAGE 16
SECTION 23 – OTHER INFORMATION						OTHER INFORMATION (CONT.)	YES NO	WHO
Do you buy or plan to buy meals from a home		฀ YES	฀ NO			Have you or anyone who lives with you who is applying
delivery or communal dining service?	8					Have you or anyone who lives with you who is applying
delivery or communal dining service?	8					moved into this county from another New York State
						moved into this county from another New York State
Are you able to cook or prepare meals at home?	9	฀ YES	฀ NO	VETERAN	VETERAN CODE	county within the past two months?
Are you able to cook or prepare meals at home?	9			STATUS		Have you or anyone who lives with you ever been found
Have you or anyone in your household ever been in the						Have you or anyone who lives with you ever been found
Have you or anyone in your household ever been in the		฀ YES	฀ NO			guilty of and/or been disqualified for Public Assistance
U.S. military?		฀ YES	฀ NO			guilty of and/or been disqualified for Public Assistance
U.S. military?						and/or the Supplemental Nutrition Assistance Program
Who? ________________________________________ 10						and/or the Supplemental Nutrition Assistance Program
Who? ________________________________________ 10						(SNAP) because of fraud/an Intentional Program
						(SNAP) because of fraud/an Intentional Program
Has your spouse ever been in the U.S. military?	11	฀ YES	฀ NO			Violation?
Has your spouse ever been in the U.S. military?	11

Is anyone in your household a dependent of someone

฀ YES

฀ NO

Have you or anyone who lives with you received benefits

for which they were not entitled, which have not been fully

who is or was in the U.S. military?

repaid to this or another agency?

Who? ________________________________________ 12

Do you or does anyone who lives with you receive assistance or services now? ฀ YES ฀ NO 13

Have you or any member of your household been

IF YES, WHO

TYPE OF ASSISTANCE

LOCATION RECEIVED

DATES RECEIVED

convicted of making a fraudulent statement or

representation of residence in order to receive Public

Assistance in two or more states?

Have you or any member of your household been

Have you or anyone who lives with you received assistance or services in the past? ฀ YES ฀ NO 14

convicted of fraudulently receiving duplicate SNAP

IF YES, WHO (Please list all

TYPE OF ASSISTANCE

LOCATION RECEIVED

DATES RECEIVED

Benefits in any state after September 22, 1996?

previous names)

Have you or any member of your household been

convicted of buying or selling SNAP Benefits for a

combined amount of over $500 or more after September

22, 1996?

NEEDED

REFERRALS

COMPLETED

CONSIDER

Have you or any member of your household been

Services



SNAP Dependent Care Deductions

convicted of trading SNAP benefits for firearms,

UIB

ammunition or explosives, or drugs?

Are you or any member of your household fleeing to avoid

prosecution, custody or confinement after conviction of a

felony or attempted felony and actively being pursued by

law enforcement?

Are you or any member of your household violating

probation or parole according to a court order?

PROPERTY TRANSFER STATUS

I have ฀ I have not ฀

sold, transferred or given away any of my property to

anyone to get Public Assistance or SNAP Benefits.

REQUESTED

DOCUMENTATION

IN FILE

Educational Grant Worksheet

Child/Dependent Care Statement

Recoupments

Outstanding Overpayment

Pending Disqualification

PAGE 17

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

IF TOTAL EXPENSES (INCLUDING EXPENSES NOT USED IN THE BUDGET DETERMINATION) EXCEED INCOME (INCLUDING PA GRANT), EXPLORE HOW THE HOUSEHOLD IS MEETING ITS OBLIGATIONS.


	Actual	$
	Expenses

	- Actual	$
	Income

		$
	= Difference

			YES	NO
			YES	NO

Does Client Receive			฀	฀
	Contribution Towards		฀	฀
	Contribution Towards

Difference

If Yes, From Whom?

________________________________

CONSIDER

Actual Expenses, including: shelter,

fuel/utility costs, telephone costs, etc.

 Actual Shelter

 Actual Fuel/Utility Costs

 Telephone Expenses

Car Expenses

Furniture/Appliance Rental

Cable TV

Tuition

Out-of-Pocket Medical Expenses

EMERGENCY CASH ASSISTANCE

Is there an immediate need? If not, why not?

NOTES/COMMENTS

LDSS-2921 Statewide (Rev. 07/20)

PAGE 18

NOTICES, ASSIGNMENTS, AUTHORIZATIONS, and CONSENTS

COLLECTION AND USE OF SOCIAL SECURITY NUMBERS – The collection of Social Security Numbers (SSNs) is authorized for each household member with respect to the Supplemental Nutrition Assistance Program (SNAP), pursuant to the Food and Nutrition Act of 2008 (as amended). Anyone applying for SNAP must provide an SSN in order to receive benefits. If you or anyone applying does not have an SSN, that person must apply for an SSN with the Social Security Administration (visit www.SSA.gov or call 1-800-772-1213).

With respect to all other programs for which this application form requires an SSN, the collection of SSNs is also mandatory and is authorized under one or more of the following sections of law: Section 205(c) of the Social Security Act (42 U.S. Code 405), Section 1137 of the Social Security Act (42 U.S. Code 1320b-7) and Section 7(a)(2) of the Privacy Act of 1974. See the instruction book (PUB-1301 Statewide) or talk to your social services district if you have questions.

The information we collect will be used to determine whether your household is eligible or continues to be eligible for assistance or benefits. The information will be used to check identity, to verify earned and unearned income, to determine if absent parents can receive health insurance coverage for applicants or recipients, to determine if applicants or recipients can obtain child or spousal support, and to determine if applicants or recipients can receive money or other help. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. Besides using the information you give us in this way, the state will use the information to prepare statistics about all of the people receiving benefits from the Home Energy Assistance Program (HEAP) (see below).

This information may be disclosed to other state and federal agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. Information collected with respect to applicants for and recipients of Family Assistance and Safety Net Assistance, including SSNs, may be used to assist in the formation of jury pools. If a SNAP claim arises against your household, the information on this application, including all SSNs, may be referred to federal and state agencies, as well as private claims collection agencies, for claims collection action.

SSNs of ineligible household members will also be used and disclosed in the manner above.

Besides using the information you give us in this way, the State also uses the information to prepare statistics about all the people receiving benefits from HEAP. The information is used for quality control by the State to make sure social services districts are doing the best job they can. It is used to verify your energy supplier and to make certain payments to such vendors.

NONDISCRIMINATION NOTICE – This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and, in some cases, religion or political beliefs.

The United States Department of Agriculture (USDA) also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a Supplemental Nutrition Assistance Program (SNAP) complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410

(2)Fax: (202) 690-7442; or

(3)Email: program.intake@usda.gov.

PAGE 19

LDSS-2921 Statewide (Rev. 07/20)

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish, or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

To file a complaint of discrimination regarding a program receiving federal financial assistance through the U.S. Department of Health and Human Services (HHS), write HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

New York State additionally prohibits discrimination based on gender identity, transgender status, gender dysphoria, sexual orientation, marital status, military status, domestic violence victim status, pregnancy-related conditions, predisposing genetic characteristics, prior arrest or conviction record, familial status, and retaliation for opposing unlawful discriminatory practices.

CONSENT FOR INVESTIGATION – I agree to any investigation to verify or confirm the information I have given in connection with my request for Public Assistance (PA), Medicaid, Supplemental Nutrition Assistance Program (SNAP) Benefits, Home Energy Assistance Program Benefits, Services or Child Care Assistance. If additional information is requested, I will provide it. I will also cooperate fully with state and federal personnel in any PA and/or SNAP Quality Control Review.

If I am applying for SNAP, I understand that the social services district will request and use information available through the Income and Eligibility Verification System to investigate my application, and may verify this information through collateral contacts if discrepancies are found. I also understand that such information may affect my eligibility for SNAP and/or the level of SNAP Benefits I receive.

CONSENT FOR RELEASE OF CONFIDENTIAL UNEMPLOYMENT INSURANCE INFORMATION – I authorize the New York State Department of Labor (DOL) to release any confidential information maintained by DOL for Unemployment Insurance (UI) purposes to the New York State Office of Temporary and Disability Assistance (OTDA). This information includes UI benefit claims and wage records. I understand that OTDA, along with state and local agency employees working in social services district offices, will use the UI information for establishing or verifying eligibility for, and the amount of, Public Assistance, Medicaid, Supplemental Nutrition Assistance Program Benefits, Home Energy Assistance Program Benefits or Child Care Assistance, applied for in this application and for investigations to determine whether I received benefits to which I was not entitled. OTDA may also share the information with the New York State Office of Children and Family Services (OCFS) and the New York State Department of Health (DOH). OCFS will use the information to monitor the Child Care Assistance program.

RELEASE OF INFORMATION TO SERVICE PROVIDERS – I give permission to the social services district and New York State to share information regarding Public Assistance or Supplemental Nutrition Assistance Program benefits that I or any member of my household for whom I can legally give authorization have received, for purposes of verifying my eligibility for services and payment related to program administration provided by a State or local contractor. Such services may include, but are not limited to, job placement or training services provided to help me or members of my household obtain and retain employment.

CHANGE REPORTING – I agree to inform the agency promptly of any change in my address, needs, income, and property, able-bodied adult without dependents (ABAWD) status, pregnancy status or living arrangements, to the best of my knowledge or belief.

If I am applying for Child Care Assistance, I agree to inform the agency immediately of any change in family income, who lives in my home, employment, child care arrangements or other changes which may affect my continued eligibility or amount of my benefit.

PENALTIES – Federal and state laws provide for penalties of fine, imprisonment or both if you do not tell the truth when you apply for Public Assistance, Medicaid, Supplemental Nutrition Assistance Program, Services or Child Care Assistance (“Assistance, Benefits or Services”) or at any time when you are questioned about your eligibility, or cause someone else not to tell the truth regarding your application or your continuing eligibility. Penalties also apply if you conceal or fail to disclose facts regarding your initial and continuing eligibility for Assistance, Benefits or Services, or if you conceal or fail to disclose facts that would affect the right of someone for whom you have applied to obtain or continue to receive Assistance, Benefits or Services. If you are an authorized representative, such Assistance, Benefits or Services must be used for the other person and not for yourself. Federal and state laws provide that any transfer of assets for less than fair market value made by an individual or an individual’s spouse, within 60 months prior to the first of the month in which the individual is

LDSS-2921 Statewide (Rev. 07/20)

PAGE 20

both in receipt of nursing facility services and has submitted an application for Medicaid, may render the individual ineligible for nursing facility services or home and community-based waivered services for a period of time. It is unlawful to obtain Assistance, Benefits or Services by concealing information or providing false information.

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM DISQUALIFICATION PENALTIES – Any information you provide in connection with your application for the Supplemental Nutrition Assistance Program (SNAP) will be subject to verification by federal, state and local officials. If any information is incorrect, you may be denied SNAP Benefits. You may be subject to criminal prosecution if you knowingly provide incorrect information which affects eligibility or the amount of benefits. Any person convicted of a felony for knowingly using, transferring, acquiring, altering or possessing SNAP authorization cards or access devices may be fined up to $250,000, imprisoned up to 20 years or both. The individual may also be subject to prosecution under the applicable federal and state laws. Anyone who is violating a condition of probation or parole, or anyone who is fleeing to avoid prosecution, custody or confinement of a felony and is actively being pursued by law enforcement, is not eligible to receive SNAP Benefits.

You may be found ineligible for SNAP or found to have committed an Intentional Program Violation (IPV) if you make a false or misleading statement, or misrepresent, conceal or withhold facts, in order to qualify for benefits or receive more benefits; purchase a product with SNAP benefits with the intent of obtaining cash by intentionally discarding the product and returning the container for the deposit amount; or commit or attempt to commit any act that constitutes a violation of federal or state law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking SNAP Benefits, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system. Additionally, the following is not allowed and you may be disqualified from receiving SNAP Benefits and/or be subject to penalties for actions that include:

•Using SNAP benefits to buy non-food items, such as alcohol or cigarettes;

•Using SNAP benefits to pay for food previously purchased on credit;

•Allowing someone else to use your EBT card in exchange for cash, firearms, ammunition or explosives, or drugs, or to purchase food for individuals who are not members of your SNAP household; or

•Using or having in your possession EBT cards that do not belong to you, without the card owner’s consent.

Individuals found to have committed an IPV either through an administrative disqualification hearing or by a federal, State or local court, or have signed either a waiver of right to an administrative disqualification hearing or a disqualification consent agreement in cases referred for prosecution shall be ineligible to participate in SNAP for a period of:

•12 months for the first SNAP IPV;

•24 months for the second SNAP IPV;

•24 months for the first SNAP IPV that is based on a court finding that the individual used or received SNAP Benefits in a transaction involving the sale of a controlled substance (illegal drugs or certain drugs for which a doctor’s prescription is required); or

•120 months if the individual is found to have made a fraudulent statement about who they are or where they live in order to get multiple SNAP Benefits simultaneously, unless permanently disqualified for a third SNAP IPV.

Additionally, a court may bar an individual from participating in SNAP for an additional 18 months.

An individual can be permanently disqualified from receiving SNAP Benefits for:

•The first SNAP IPV based on a court finding that the individual used or received SNAP Benefits in a transaction involving the sale of firearms, ammunition or explosives;

•The first SNAP IPV based on a court conviction for trafficking SNAP Benefits for a combined amount of $500 or more (trafficking includes the illegal use, transfer, acquisition, alteration or possession of SNAP authorization cards or access devices);

•The second SNAP IPV based on a court finding that the individual used or received SNAP Benefits in a transaction involving the sale of a controlled substance (illegal drugs or certain drugs for which a doctor’s prescription is required); or

•A third SNAP IPV.

REQUIREMENT TO REPORT/VERIFY HOUSEHOLD EXPENSES – Your household must report child care and utility expenses in order to get a Supplemental Nutrition Assistance Program (SNAP) deduction for these expenses. Your household must report and verify rent/mortgage payments, property taxes, insurance, medical expenses and child support paid to a non-household member in order to get a SNAP deduction for these expenses. Failure to report/verify the above expenses will be seen as a statement by your household that you do not want to receive a deduction for these unreported/unverified expenses. A deduction for these expenses may make you eligible for SNAP or may increase your SNAP benefits. You may report/verify these expenses at any time in the future. The deduction would then be applied to the calculation of SNAP benefits in future months, in accordance with the rules for change reporting (see Change Reporting, above).

PAGE 21

LDSS-2921 Statewide (Rev. 07/20)

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to apply for Supplemental Nutrition Assistance Program (SNAP) Benefits for you. You can also authorize someone outside your household to get SNAP Benefits for you or to use them to buy food for you. If you would like to authorize someone, you must do so in writing. You may authorize someone by printing the person’s name, address, and phone number immediately below, and having them sign in the signature section at the end of this application. When an Authorized Representative is applying on behalf of a SNAP household that does not reside in an institution, both the Authorized Representative and a responsible adult member of the household must sign and date the signature section at the end of this application, unless the SNAP household has otherwise designated the Authorized Representative to do so in writing.

NAME, ADDRESS AND PHONE NUMBER OF AUTHORIZED REPRESENTATIVE (PLEASE PRINT):

STANDARD UTILITY ALLOWANCE – I understand that Public Assistance and Supplemental Nutrition Assistance Program (SNAP) recipients are categorically income eligible for the Home Energy Assistance Program (HEAP). I also understand that if I have not received a HEAP benefit of greater than $20 in the current month or previous 12 months, or a similar energy assistance benefit, I must pay for heating or air conditioning separately from my rent in order to receive the heating/cooling standard utility allowance (i.e., a deduction) for SNAP. I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my annual electricity usage, electricity cost, fuel consumption, fuel type, annual fuel cost and payment history to the New York State Office of Temporary and Disability Assistance, the local social services district and the United States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program performance measurement.

RELEASE OF MEDICAL INFORMATION – I consent to the release of any medical information about me and any members of my family for whom I can give consent by my primary care provider, any other health care provider or the New York State Department of Health (DOH) to my health plan and any health care providers involved in caring for me or my family, as reasonably necessary for my health plan or my providers to carry out treatment, payment, or health care operations; by my health plan and any health care providers to DOH and other authorized federal, state, and local agencies for purposes of administration of Medicaid; and, by my health plan to other persons or organizations, as reasonably necessary for my health plan to carry out treatment, payment, or health care operations. I authorize the release of any health-related information about me and any members of my family for whom I can legally give authorization related to the provision of assistance and services and my ability to participate in work activities, including employment, to the New York State Office of Temporary and Disability Assistance (OTDA), the New York State Office of Children and Family Services or the local social services district, as reasonably necessary for the provision of Public Assistance benefits; for services, including child welfare services; for determining appropriate work activity assignments; for determining the need to apply and for making application for Supplemental Security Income Benefits; for establishing appropriate treatment plans for restoring employability; and for determining eligibility for exemptions from the State sixty-month time limit on cash assistance receipt. If I am required to apply for benefits administered by the Social Security Administration, the information specified above may be shared with the Social Security Administration. I also agree that the information released may include HIV, mental health or alcohol and substance abuse information about me and members of my family, to the extent permitted by law, unless a box is checked below. If more than one adult in the family is joining a Medicaid health plan, the signature of each adult applying is necessary for consent to release information. I understand that my ability to consent to the release of information relating to any minor children for whom I may give consent is limited by the extent to which I can obtain information regarding treatment, diagnosis and procedures on their behalf.

_______ Do not disclose HIV/AIDS information	______ Do not disclose drug and alcohol information
_______ Do not disclose mental health information

RELEASE OF INFORMATION TO HEALTH SERVICE PROVIDERS – I give permission to the social services district and the State of New York to share information with health service providers, as designated by the social services district or the State of New York, regarding Public Assistance benefits that I or any member of my household for whom I can legally give authorization have received or are eligible to receive, for the purpose of improving the quality of my healthcare and overall well-being, and to facilitate receipt of additional benefits for which I, or members of my household, may be eligible.

LDSS-2921 Statewide (Rev. 07/20)

PAGE 22

RELEASE OF EDUCATIONAL RECORDS – I give permission to the New York State Department of Health and the social services district to:1) obtain any information regarding the educational records of myself and/or my minor child(ren), herein named, including information necessary for claiming Medicaid reimbursement for health-related educational services; and 2) provide the appropriate federal government agency access to this information for the sole purpose of audit.

RELEASE OF INFORMATION FOR THE EARLY INTERVENTION PROGRAM – If my child is evaluated for or participates in the New York State Early Intervention Program, I give permission to the social services district and New York State to share my child’s Medicaid eligibility information with my county or municipal Early Intervention Program for the purpose of billing Medicaid.

CHILD/TEEN HEALTH PROGRAM – I understand that if my child is on Medicaid, they can get comprehensive primary and preventive care, including all necessary treatment through the Child/Teen Health Program. I can get more information on this program from the social services district.

MEDICARE – I authorize payments under “Medicare” (Part B of Title XVIII, Supplementary Medical Insurance Program) to be made directly to physicians and medical suppliers on any future unpaid bills for medical and other health services furnished to me while I am eligible for Medicaid.

REIMBURSEMENT OF MEDICAL EXPENSES

MEDICAID – You have a right as part of your Medicaid application, or within two years from the date of your application, to request reimbursement of expenses you paid for covered medical care, services and supplies received during the three-month period prior to the month of your application. After the date of your application, reimbursement of covered medical care, services and supplies will only be available if obtained from Medicaid-enrolled providers.

ASSIGNMENT OF INSURANCE/OTHER BENEFITS AND DIRECT PAYMENT – For Public Assistance and Medicaid, I agree to file any claims for health or accident insurance benefits, and to pursue any personal injury claims or any other resources to which I may be entitled, and do hereby assign any such resources to the social services district to whom this application is made. In addition, I will assist in making any assigned benefits available to the social services district to whom this application is made.

I authorize payments owed to me or members of my household for health or accident insurance benefits to be made directly to the appropriate social services district for medical and other health services furnished while we are eligible for Medicaid.

MEDICAID RECOVERIES – Upon receipt of Medicaid, a lien may be filed and a recovery may be made against your real property under certain circumstances if you are in a medical institution and not expected to return home. MA paid on your behalf may be recovered from persons who had legal responsibility for your support at the time medical services were obtained. MA may also recover the cost of services and premiums incorrectly paid.

I understand that effective April 1, 2014, if I get Medicaid through New York State of Health:

•No lien will be placed on my real property prior to my death.

•Recovery from assets in my estate upon my death is limited to the amount Medicaid paid for the cost of nursing home care, home and community-based services, and related hospital and prescription drug services received on or after my 55th birthday.

PUBLIC ASSISTANCE RECOVERIES – Public Assistance (PA) you receive for yourself and for persons for whom you are legally responsible to support is recoverable from property or money you possess or may acquire. You may be required, as a condition of receiving PA, to execute a deed or mortgage of real property you own. Your tax refunds and portions of lottery winnings may be taken to repay your debt for PA.

AUTHORIZATION TO REPAY PUBLIC ASSISTANCE BENEFITS FROM RETROACTIVE SUPPLEMENTAL SECURITY INCOME – I authorize the Commissioner of the Social Security Administration (SSA) to use my first payment of Supplemental Security Income (SSI); i.e. my retroactive SSI payment) to reimburse the local social services district (SSD) for

PAGE 23

LDSS-2921 Statewide (Rev. 07/20)

Public Assistance (PA) the SSD pays me from State or local funds while SSA decides if I am eligible for SSI. SSA will not reimburse the SSD for PA that was paid using any federal funds.

I will be bound by this authorization only if the State gives notice to SSA that I and an SSD representative have signed it. The State must give notice within 30 calendar days of matching my SSI record with my State record. SSA will not accept it after 30 calendar days. Instead, SSA will send me my retroactive SSI payment under SSA rules.

Only my first payment of SSI can be used. If my first payment is larger than the amount owed to the SSD, SSA will send the rest to me under its rules.

SSA can reimburse the SSD in two situations:

(1)It will repay the SSD if I apply for SSI and SSA finds me eligible.

(2)It will repay the SSD if my SSI benefits are reinstated after termination or suspension.

SSA will only reimburse the SSD for PA it paid me during the time I am waiting for an SSA determination of eligibility. This is called “interim assistance.” The period begins: 1) with the first month I become eligible for payment of SSI benefits; or 2) on the first day I am reinstated after my SSI was suspended or terminated. The period includes the month SSI payments actually begin. If the SSD cannot stop my last PA payment, the period ends the next month.

No later than 10 days after SSA reimburses the SSD, the SSD must send me a notice telling me the amount of interim assistance paid. The notice will also tell me that SSA will send me a letter telling me how any remaining SSI money owed to me will be sent by SSA and that, if I do not agree with a state decision, how I can appeal the decision to the state.

Under its rules, SSA may use the date I sign this authorization as the date I first become eligible for SSI. It will do this only if I apply for SSI within the next 60 days.

This authorization applies to any SSI application or appeal I now have pending before SSA. This authorization terminates if my SSI case is completely decided. It terminates when SSA first pays me. The State and I can also agree to terminate the authorization. I must sign a new authorization consistent with NYS rules if I reapply for SSI after this authorization terminates, or if I file a new SSI claim while I have an SSI application or appeal pending.

I will be given an opportunity for a fair hearing if I disagree with a decision the SSD made about reimbursement.

I received a copy of the pamphlet called “What You Should Know About Social Services Programs.” I understand what it says about interim assistance.

SUPPORT – Applying for or receiving Family Assistance (FA), Safety Net Assistance (SNA) or Title IV-E foster care operates as an assignment to the State and the social services district of any rights to support from any other person that the applicant or recipient may have in their own right or on behalf of any other family member for whom the applicant or recipient is applying for, or receiving, assistance (Social Services Law, Sections 158 and 348). This assignment is limited in certain situations. Other sections of this application contain additional assignments.

ASSIGNMENT OF SUPPORT RIGHTS – I assign to the state and social services district any rights I have to support from persons having legal responsibility for my support and any rights I have to support on behalf of any family member for whom I am applying for or receiving assistance. Where applying for or receiving Family Assistance or Safety Net Assistance, my assignment of support rights is limited to support which accrues during the period that I and/or any family member receives assistance. However, any support rights that I assigned to the state on behalf of myself or any family member prior to October 1, 2009, continue to be assigned to the state.

HOME ENERGY ASSISTANCE PROGRAM – I understand that by signing this application/certification, I consent to any investigation to verify or confirm the information I have given and other investigation by any authorized government agency in connection with Home Energy Assistance Program (HEAP) benefits. I also consent to allow the information provided on this application to be used in referrals to available weatherization assistance programs and my utility company’s low income programs.

I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my annual electricity usage, electricity cost, fuel consumption, fuel type, annual fuel cost and payment history to the New York State Office of Temporary and Disability Assistance, the local social services district and the United States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program performance measurement.

SEXUAL ASSAULT INFORMATION – If you are a victim of sexual assault, you have the right to request referral information from the social services district. If you request referral information, the social services district must provide you with the addresses and phone numbers of any: 1) local hospitals offering sexual assault forensic examiner services certified by

LDSS-2921 Statewide (Rev. 07/20)

PAGE 24

the NYS Department of Health; 2) local rape crisis centers; and 3) local advocacy, counseling, and hotline services appropriate for victims of sexual assault. In addition, the social services district must provide you with the NYS Hotline for Sexual Assault and Domestic Violence numbers: (800) 942-6906 and (800) 818-0656 (TTY).

CERTIFICATION FOR CHILD CARE ASSISTANCE – If I am applying for Child Care Assistance, I certify that my family resources do not exceed $1,000,000.

I have read and understand the notices above. I understand and agree to the assignments, authorizations and consents above. I swear and/or affirm under the penalties of perjury that the information I have given or will give to the social services district is complete and correct.

APPLICANT SIGNATURE	DATE SIGNED	SPOUSE OR PROTECTIVE REPRESENTATIVE SIGNATURE	DATE SIGNED
x		x

AUTHORIZED REPRESENTATIVE	DATE SIGNED
SIGNATURE
x

ONLY COMPLETE THE FOLLOWING IF YOU WANT TO WITHDRAW YOUR APPLICATION FOR ONE OR MORE PROGRAMS.

I Consent to Withdraw My Application For:
฀ Public Assistance (PA) ฀ Child Care in lieu of PA	฀ Supplemental Nutrition Assistance Program (SNAP) ฀ Medicaid and SNAP
฀ Medicaid and PA ฀ Services, including Foster Care	฀ Child Care Assistance	฀ Emergency Assistance Only
I understand that I may reapply at any time.
APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE		DATE SIGNED
x

NYS Agency-Based Voter Registration Form

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

Important!

like to apply to register here today?”

Applying to register or declining to register to vote will not affect the

If you checked YES, please complete the

If you do not check

amount of assistance that you will be provided by this agency.

YES

any box, you will

VOTER REGISTRATION APPLICATION below

If you would like help filling out the voter registration application form,

be considered to

NO because I choose not to register OR

have decided not

we will help you. The decision whether to seek or accept help is yours.

I am already registered at my current address OR

to register to vote

You may fill out the application form in private.

at this time.

Información en español: si le interesa obtener este formulario en español,

I asked for and received a mail registration form

LLAME AL 1-800-367-8683

中文資料:若您有興趣索取中文資料表格,請電: 1-800-367-8683

한국어: 한국어 한국어 양식을 원하시면 1-800-367-8683

Signature

Date

으로 전화 하십시오.

যিদ আপিন এই ফর্মিট বাংলা ভাষায় চান , তাহেল

Please Print Name

1-800-367-8683 নমব্ের ফন করুন

VOTER REGISTRATION APPLICATION (instructions on back)

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?

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

YES

For Board Use Only

B) Are you at least 16 years of age and understand that you must be 18

YES

years of age on or before election day to vote, and that until you will

be eighteen years of age at the time of such election your registration

will be marked “pending” and you will be unable to cast a ballot in any

If you answered NO, do not complete this form

election?

YES

If you answered NO to both of the prior questions, you cannot register to vote.

Last Name

First Name

Middle Initial

Suffix

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

Apt. No.

City/Town/Village

Zip Code

County

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

P.O. Box, Star Route, etc.

Post Office

Zip Code

Date of Birth

Gender (optional)

Telephone (optional)

Email (optional)

The last year you voted

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

ID Number (Check the applicable box and provide your number)

New York State DMV number

In county/state

Under the name (if different from your name now)

Last four digits of your Social Security number

I do not have a New York State DMV or Social Security number

Political Party

Affidavit: I swear or affirm that

• I am a citizen of the United States.

I wish to enroll in a political party

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

Democratic party

Libertarian party

the election.

Republican party

Independence party

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

Conservative party

SAM party

• This is my signature or mark on the line below.

Working Families party

Other

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

Green party

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

I do not wish to enroll in any political party and wish to be an independent voter

No 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	City/Town/Village				Zip Code

Birth Date		Gender
			M			F

Eye Color		Height
				Ft.			In.

Email		DMV or ID NYC Number

By signing below, you certify that you are:

•16 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 NYS Donate Life Registry for enrollment;

•And authorizing the Registry to allow access to this information to federally regulated

organ procurement organizations and NYS-licensed tissue and eye banks and others approved by the NYS Commissioner of Health hospitals upon your death.

/ /

Signature

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;

•pre-register to vote if you are 16 or 17 years of age.

To Register You Must:

•be a U.S. citizen;

•be 18 years old (you may pre-register at 16 or 17 but cannot vote until you are 18);

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

•not be in prison or on parole for a felony conviction (unless parole pardoned or restored rights of citizenship);

•not claim the right to vote elsewhere; and

•not found to be incompetent by a court.

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:

NYS Board of Elections

40 North Pearl St, Suite 5

Albany, NY 12207-2729

Telephone: 1-800-469-6872;

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

or visit our web site - www.elections.ny.gov

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 registration 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, paycheck, 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. Political party enrollment is optional but that, in order to vote in a primary election of a political party, a voter must enroll in that political party, unless state party rules allow otherwise.

Rev. 2/05/2020

Question	Answer
Form Name	Ldss 2921 Form
Form Length	28 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	7 min
Other names	cash assistance application nyc, cash assistance application nyc form, nyc public assistance application form, public assistance application form

฀ Pregnant		1
฀ Victim of Domestic Violence		2
฀ Need to Establish Parentage		3
฀ Need Child Support		4
฀ Drug/Alcohol Problem		5
฀ Fuel or Utility Shutoff		6
฀ No Place to Stay/Homeless		7
฀ Fire or Other Disaster		8
฀ Have No Income		9
฀ Serious Medical Problem		10
฀ Pending Eviction		11
฀ No Food		12
฀ Need Foster Care		13
฀ Need Child Care		14
฀ Problems with English		15
฀ Reasonable Accommodations		16
฀ Other		17

LDSS-2921 Statewide (Rev. 07/20)	DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION		PAGE 2
		Does This Person (Including
SECTION 6 – HOUSEHOLD INFORMATION – List everybody who lives with you, even if they are not applying with you. List yourself on the first line.		Minor Children) Buy Food or
		Prepare Meals with You?
		Prepare Meals with You?

Ldss 2921 Form – Fill Out and Use This PDF

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