Ldss 2921 Form PDF Details

Are you interested in submitting a complaint about a place of public accommodation? Do you want to file a lawsuit against an employer for violating the Americans with Disabilities Act? Or, do you just need information on how to properly complete the Ldss 2921 Form? Regardless of your knowledge level or purpose, this blog post is here to provide you with everything that you need to know about the Ldss 2921 Form. We'll dissect its elements and discuss instructions that are important for completing it correctly so that all associated parties can be made aware and taken into consideration. So keep reading on if this form is something relevant to your situation!

QuestionAnswer
Form NameLdss 2921 Form
Form Length28 pages
Fillable?No
Fillable fields0
Avg. time to fill out7 min
Other namescash assistance application nyc, cash assistance application nyc form, nyc public assistance application form, public assistance application form

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

CATEGORY

LANG

NUMBER

OFFICE

 

 

 

TYPE

IND

 

 

 

 

 

 

SUFFIX

 

 

REUSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDICATOR

CASE NAME

 

 

 

 

 

 

DISPOSITION

 

 

 

SERVICES TRANSACTION TYPE

 

 

 

 

 

 

 

 

EFFECTIVE DATE

 

 

 

NEW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPENING

REOPEN

 

RECERTIFICATION

 

 

 

 

 

 

 

DENIAL

REASON CODE

WITHDRAWAL

02

 

10

06

 

 

 

 

 

 

 

 

 

 

 

 

 

ELIGIBILITY DETERMINED BY (WORKER):

DATE

ELIGIBILITY APPROVED BY (SUPERVISOR):

DATE

 

 

SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY

DATE

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM __________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0F _____________

x

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE RECEIVED BY AGENCY

 

 

 

SOCIAL SERVICES DISTRICT

PROVIDER AGENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYED BY:

SPECIFY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PA AUTHORIZATION PERIOD

 

 

MA AUTHORIZATION PERIOD

 

 

 

SNAP AUTHORIZATION PERIOD

 

SERVICES AUTHORIZATION PERIOD

 

 

FROM

 

 

TO

 

FROM

 

TO

 

 

 

FROM

 

 

TO

 

FROM

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEW YORK STATE APPLICATION FOR CERTAIN BENEFITS AND SERVICES

If you are blind or seriously visually impaired and need this application in an alternative format, you may request one from your social services district. For additional information regarding the types of formats available and how you can request an application in an alternative format, see the instruction book (PUB-1301 Statewide), available at www.otda.ny.gov or https://www.health.ny.gov/.

If you are blind or seriously visually impaired, would you

like to receive written notices in an alternative format? Yes

If yes, check the type of format you would like: Large Print ฀ ฀ Audio CD

No

Data CD

Braille, if you assert that none of the other alternative formats will be equally effective for you

If you require another accommodation, please contact your social services district.

We are committed to assisting and supporting you in a professional and respectful manner. You are responsible for participating in activities, including work activities for Public Assistance and the Supplemental Nutrition Assistance Program, where required, so you can become self-sufficient. Whenever you see “Public Assistance” or “PA” on the application, it means “Family Assistance” and/or “Safety Net Assistance.” We call both programs “Public Assistance.” These PA programs are meant to assist you only until you can fully support yourself and your family. Please refer to the instruction book (PUB-1301 Statewide) and “What You Should Know”

Books 1, 2 and 3 (LDSS-4148A, LDSS-4148B, and LDSS-4148C) when completing this application, and contact your social services district with any questions.

When you see “MA” on the application, it means “Medicaid.” You may apply for MA using this application only if you are also applying for Public Assistance or the Supplemental Nutrition Assistance Program at the same time. If you wish to only apply for MA, you can go online at https://nystateofhealth.ny.gov/ and/or call 1-855-355-5777 for more information or to apply, or you may use the MA-only paper application - Form DOH-4220, which your worker can give you, or call MA help line at 1-800-541-2831. If you want to apply only for the Medicare Savings Program (MSP), you must apply with Form DOH-4328, which your worker can provide to you. If you have an immediate need for personal care services, you should apply for MA separately using the DOH- 4220 MA application form.

PAGE 1

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION

LDSS-2921 Statewide (Rev. 07/20)

SECTION 1

CHECK EACH PROGRAM YOU OR ANY HOUSEHOLD

MEMBER ARE APPLYING FOR

Public Assistance (PA) Child Care in lieu of PA Supplemental Nutrition Assistance Program (SNAP) Medicaid (MA) and SNAP

Medicaid (MA) and PA Services (S), including Foster Care (FC) Child Care Assistance (CC) Emergency Assistance Only (EMRG)

SECTION 2

WHAT IS YOUR

ENGLISH

 

 

SPANISH

 

DO YOU WANT TO

ENGLISH ONLY ENGLISH AND SPANISH

PRIMARY

 

 

 

RECEIVE NOTICES IN:

LANGUAGE?

OTHER (specify) ________

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 3

 

 

 

 

 

APPLICANT INFORMATION

 

 

 

PLEASE PRINT CLEARLY

FIRST NAME

 

 

 

M.I.

LAST NAME

 

 

 

 

 

 

MARITAL

 

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AREA CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

APT. NO.

CITY

 

COUNTY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN CARE OF NAME (COMPLETE IF YOU RECEIVE YOUR MAIL IN CARE OF ANOTHER PERSON)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (IF DIFFERENT FROM ABOVE)

 

 

 

 

APT. NO.

CITY

 

COUNTY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOW LONG

YEARS

MONTHS

IS THIS A SHELTER?

ANOTHER PHONE

NAME

 

 

 

 

 

PHONE NUMBER

HAVE YOU LIVED

 

 

 

YES

NO

WHERE YOU

 

 

 

 

 

 

(

)

 

AT YOUR

 

 

 

 

 

 

CAN BE

 

 

 

 

 

 

 

AREA CODE

 

PRESENT ADDRESS?

 

 

 

 

 

 

REACHED

 

 

 

 

 

 

 

 

 

 

DIRECTIONS TO CURRENT ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORMER ADDRESS

 

 

 

 

 

 

 

APT. NO.

CITY

 

COUNTY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YOU ARE CURRENTLY WITHOUT A HOME, CHECK HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY HELPING APPLICANT/CONTACT PERSON

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

( )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AREA CODE

 

 

 

 

DO YOU NEED THE MEDICAID PORTION OF THIS APPLICATION AND THE POTENTIAL RECEIPT OF ANY MEDICAID COVERAGE TO BE KEPT CONFIDENTIAL?

YES

NO

 

SECTION 5

DO ANY OF THESE APPLY TO YOU?

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

SECTION 4 – If You Are Applying For SNAP: You can file an application the day you get it. In order to file a SNAP application, it must have, at minimum, your name, address (if you have one) and signature below. You must complete the application process, including signing the last page of the application and being interviewed. If eligible, you will get SNAP benefits back to the date you filed the application. You must be told, within 30 days of the date you turned in (filed) your application for SNAP benefits, if your application is approved or denied. If your household has little or no income or liquid resources, or if your rent and utility expenses are more than your income and liquid resources, you may be eligible to get SNAP benefits within five calendar days of the date you file. If you are a resident of an institution and are applying for both Supplemental Security Income (SSI) and SNAP benefits prior to leaving the institution, the filing date of the application is the date you leave the institution.

SNAP APPLICANT/REPRESENTATIVE SIGNATURE

X

DATE SIGNED

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Highest School

 

 

 

 

 

 

 

 

 

 

 

 

Grade Completed

 

 

 

 

This person is applying for:

 

 

Gender Identity (Optional):

 

Social Security Number

 

 

 

 

Date of Birth:

Sex:

Relationship

of Applying Household Members

 

RI LN

First Name, Middle Initial, Last Name

 

 

 

(Male, Female, Non-Binary, X,

 

 

 

 

(See instruction book,

 

 

 

PA SNAP MA

CC

FC

S EMRG

(mm/dd/yyyy)

(M/F)

Transgender, Different Identity

to you:

PUB-1301 Statewide, or talk to your

YES

 

 

 

 

[please describe])

NO

 

 

 

 

 

 

 

 

 

 

social services district)

 

 

01

 

 

 

 

 

 

 

 

SELF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

02

 

 

 

 

 

 

 

 

 

 

 

 

03

 

 

 

 

 

 

 

 

 

 

 

 

04

 

 

 

 

 

 

 

 

 

 

 

 

05

 

 

 

 

 

 

 

 

 

 

 

 

06

 

 

 

 

 

 

 

 

 

 

 

 

07

 

 

 

 

 

 

 

 

 

 

 

 

08

 

 

 

 

 

 

 

 

 

 

 

 

 

Line No. ONC

FIRST NAME

 

M.I.

LAST NAME

 

 

 

 

 

 

 

PLEASE LIST MAIDEN OR

 

 

 

 

 

 

 

 

 

 

 

OTHER NAMES BY WHICH

 

 

 

 

 

 

 

 

 

 

 

YOU OR ANYONE IN YOUR Line No. ONC

FIRST NAME

 

M.I.

LAST NAME

 

 

 

 

 

 

 

HOUSEHOLD HAVE BEEN

 

 

 

 

 

 

 

 

 

 

 

KNOWN

 

 

 

 

 

 

 

 

 

 

 

 

IS ANYONE

YES

NO

IF YES, WHO

 

 

REASON

 

 

END DATE

 

 

 

 

 

 

 

 

 

 

SANCTIONED?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-APPLICANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEGALLY

 

 

 

 

 

 

 

 

 

 

 

 

RESPONSIBLE

 

FOR

CONTRIBUTION/

CHECK IF MEMBER

 

 

 

 

 

 

 

 

 

LN

 

FIRST NAME

 

 

LAST NAME

YES

NO

 

WHOM?

DEEMED INCOME

OF SNAP HOUSEHOLD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-CITIZEN WITH SATISFACTORY IMMIGRATION STATUS INFORMATION

 

 

 

 

 

 

 

INDIVIDUAL EDUCATION

 

CONSIDER

NON-CITIZEN STATUS

STATUS

 

DATE OF

 

APPLIED FOR

SPONSORED

LN

DEGREE RECEIVED

LN

DEGREE RECEIVED

RCA/RMA REFERRAL

ADJUSTED

ENTRY/STATUS

CITIZENSHIP

 

 

 

 

 

 

LN

YES

NO

MONTH

DAY

YEAR

YES

NO

YES

NO

01

 

05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

02

 

06

 

 

 

 

 

 

 

 

 

 

 

 

 

03

 

07

 

 

 

 

 

 

 

 

 

 

 

 

 

04

 

08

 

 

 

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

 

 

 

 

 

 

 

 

 

H

HISPANIC OR LATINO

 

 

 

 

NUMBER

 

 

 

 

 

 

 

 

LN

 

 

 

 

 

 

 

 

 

 

 

 

 

I

NATIVE AMERICAN OR ALASKAN NATIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

ASIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

BLACK OR AFRICAN AMERICAN

 

 

 

 

 

 

 

 

 

 

 

 

 

P

NATIVE HAWAIIAN OR PACIFIC ISLANDER

 

 

 

 

 

 

 

 

 

 

 

 

W

WHITE

 

 

 

 

REL

SSN

SFUI

MS

SI

LA

EM

CI

EL

U

UNKNOWN (MA ONLY)

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

H

I

A

B

P

W

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

01

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

02

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

04

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

06

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

07

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

08

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

S

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

PA

N

 

CC

F

 

 

M

 

LN

FIRST NAME

 

MI

 

LAST NAME

 

"NON-CITIZEN"

 

 

NUMBER) OR NON-CITIZEN NUMBER

 

 

 

DATE

 

MA

S

 

 

 

 

 

 

 

 

CERTIFICATION

 

 

 

A

C

 

R

 

 

 

 

 

 

 

(If Applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for each person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

G

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

01

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

02

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

03

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

04

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

05

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

06

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

07

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

08

 

 

 

 

 

CITIZEN/

A

 

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

2.

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

 

 

 

 

3.

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

MARRIED

HEAD OF

 

QUALFIYING

 

DEPENDENT

 

WILL NOT BE

 

 

 

INITIAL

 

 

 

 

 

 

FILING

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

 

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

NO

WHO

AMOUNT/VALUE &

WHO

AMOUNT/VALUE &

CD

 

 

 

 

 

 

 

INCOME

 

 

 

 

 

 

 

 

FREQUENCY

 

FREQUENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment Insurance Benefits

 

 

 

 

 

 

 

49

LN

 

SOURCE

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

No.

 

CODE

 

 

 

AMOUNT

PERIOD

Supplemental Security Income (SSI) Benefits (State and Federal

 

 

 

 

 

 

 

45

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Disability (SSD) Benefits

 

 

 

 

 

 

 

42

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Dependent Benefits

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Survivor’s Benefits

5

 

 

 

 

 

 

43

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Retirement Benefits

6

 

 

 

 

 

 

44

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Railroad Retirement Benefits

7

 

 

 

 

 

 

38

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement Benefits (Pensions)

8

 

 

 

 

 

 

39

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

9

 

 

 

 

 

 

03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Workers’ Compensation

10

 

 

 

 

 

 

59

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NYS Disability Benefits

11

 

 

 

 

 

 

33

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Veteran’s Pension/Benefits/Aid and Attendance

12

 

 

 

 

 

 

55

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Public Assistance Grant

13

 

 

 

 

 

 

37

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GI Dependency Allotments

14

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Education Grants or Loans

15

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contributions/Gifts (Received)

16

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foster Care Payments (Received)

17

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support Payments (Received)

 

 

 

 

 

 

 

06

 

 

 

 

 

 

CONSIDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Received From:________________________________________18

 

 

 

 

 

 

 

Child Support Disregard/Pass-Through

 

 

 

 

 

 

 

 

 

 

Explained

Budgeted

 

 

Spousal Support (Received)

19

 

 

 

 

 

 

02

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SNAP Aged/Disabled Indicator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Private Disability Insurance - Health/Accident Insurance Policy

 

 

 

 

 

 

 

 

Disability Review

 

 

Income

20

 

 

 

 

 

 

 

Reception and Placement Grant (SNAP

No-Fault Insurance Benefits

21

 

 

 

 

 

 

50

 

 

Only)

 

 

 

 

 

 

 

 

 

Union Benefits (including Strike Benefits)

22

 

 

 

 

 

 

 

Refugee Matching Grant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Loans, Other than Education (Received)

23

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

24

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Training Allotments/Stipends

25

 

 

 

 

 

 

31

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rental Income (Received)

26

 

 

 

 

 

 

14

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Boarders/Lodgers Income (Received)

27

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

WHO

 

 

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

NO

 

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:

 

 

 

 

 

 

 

1

 

 

 

 

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:

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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: _________________________________________

 

 

 

 

 

3

 

 

 

 

 

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: _________________________________________

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

expenses?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who: _________________________________________

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

When the strike began: ___________________________

 

 

 

 

 

 

 

 

Are you or is anyone who lives with you a migrant or seasonal farm

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

 

 

 

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™)

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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: _______________

 

2

 

 

 

 

 

 

 

CONSIDER

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

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

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates attended ________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates completed _______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

college?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Where

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is under 16 years of age and is attending school?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

 

 

School

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

Who

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

NO

WHO

AMOUNT/VALUE

WHO

AMOUNT/VALUE

 

 

NEEDED

 

REFERRAL

 

 

COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has cash available

1

 

 

 

 

 

 

 

 

 

 

 

 

Legal

 

 

 

 

 

Has a checking account(s)

2

 

 

 

 

 

 

 

 

 

 

 

 

Resource

 

 

 

 

 

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

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a credit union account(s)

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has life insurance

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has title or registration to a motor vehicle(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

LIFE INSURANCE

 

 

 

or other vehicle(s):

 

 

 

 

 

 

 

 

 

 

FACE AMOUNT

 

CASH VALUE

Year ________ Make/Model ____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year ________ Make/Model ____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other______________________________________________ 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has stocks, bonds, certificates or mutual funds

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has savings bonds

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has an irrevocable burial trust

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a burial fund

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a burial space

12

 

 

 

 

 

 

 

REQUESTED

 

DOCUMENTATION

IN FILE

 

 

 

 

 

 

 

 

 

 

 

 

Resource

 

Checklist

 

 

 

 

 

Has their own home

13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has real estate, including income-producing and

 

 

 

 

 

 

 

 

 

 

 

 

Market Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DMV Clearance

 

 

 

 

 

non-income-producing property

14

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bank Statement

 

 

 

 

 

Is eligible for an income tax refund

15

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has an annuity

16

 

 

 

 

 

 

 

 

 

 

 

Assignment

 

of Proceeds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Car/Vehicle

 

Title

 

 

 

 

 

Is the beneficiary of a trust

17

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Car/Vehicle

 

Registration

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Older Models)

 

 

 

 

 

income from any other sources

18

 

 

 

 

 

 

 

 

 

 

 

Bank Clearance

 

 

 

 

 

Has an “in trust” account(s)

19

 

 

 

 

 

 

 

 

 

 

 

RFI/OCA

 

 

 

 

 

 

 

Has a safe deposit box(es)

20

 

 

 

 

 

 

 

 

 

 

 

1099

 

 

 

 

 

 

 

Has resources other than those listed above

21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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?

22

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

NO

IF YES, WHO

 

 

 

 

 

 

Med/Psych Statement

 

 

Has any medical bills or medically-related expenses

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug/Alcohol Screening (LDSS-4571)

 

 

 

 

 

 

 

 

 

 

 

Is on Medicaid with a spend-down

2

 

 

 

 

 

 

 

 

 

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)

3

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY OF PAYMENT:

 

 

 

 

CONSIDER

 

 

 

 

 

 

 

 

AD/SSI Related

 

 

Has health insurance available through an employer

4

 

 

 

INSURANCE COMPANY NAME:

 

 

 

 

 

 

 

SNAP Aged/Disabled Indicator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHO IS COVERED:

 

SNAP Medical Deduction

 

 

Has Medicare (red, white, and blue card)

5

 

 

 

 

 

 

 

 

 

 

TPHI Reimbursement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EFFECTIVE DATE:

 

Buy-In Eligibility

 

 

Has a health attendant/home health aide

6

 

 

 

 

 

 

 

 

 

 

Kreiger (LDSS-3664)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Violence

 

 

Is blind, sick or disabled

7

 

 

 

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

8

 

 

 

 

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

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Interview (LDSS-1151)

 

 

 

 

 

 

 

 

 

 

 

 

 

Has paid or unpaid medical bills within 3 months preceding

 

 

 

 

 

 

 

 

 

 

Medical Report (LDSS-486, 486t)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the month of this application

10

 

 

 

 

 

 

 

 

 

Disability Report

 

 

Is or was drug or alcohol dependent

11

 

 

 

 

 

 

 

 

 

AD

 

 

Needs home care/personal care

12

 

 

 

 

 

 

 

 

 

TPHI

 

 

Is on SSI or has ever applied for SSI

13

 

 

 

 

 

 

 

 

 

ACCES-VR

 

 

 

 

 

 

 

 

 

 

 

CTHP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is pregnant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family Planning

 

 

If pregnant, due date: _____________________________

14

 

 

 

 

 

 

 

 

 

 

 

Expected number of births: _________________________

 

 

 

 

 

 

 

 

 

 

SSA (RSDI)

 

 

Receives treatment from a drug abuse or alcohol treatment

 

 

 

 

 

 

 

 

 

 

Veteran’s Benefits

 

 

program

15

 

 

 

 

 

 

 

 

 

Veteran’s Counseling

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

Child Health Plus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a disability or illness

16

 

 

 

 

 

 

 

 

 

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

17

 

 

 

 

 

 

 

 

 

Home Care

 

 

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

 

 

 

 

 

 

 

 

 

NYSoH

 

 

years

18

 

 

 

 

 

 

 

 

 

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 _____________________

19

 

 

 

 

 

 

 

 

 

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?

 

 

 

 

 

 

 

 

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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,

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

NO

 

IF YES,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

expenses separate from your rent or other shelter expense?

 

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

hot water, etc.)

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

water, etc.)

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN WHOSE NAME IS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE BILL?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTHLY

 

 

 

MONTHLY

NAME OF

ACCOUNT

(CUSTOMER OF

WHO IS THE TENANT

 

Water

 

3

 

 

$

 

 

 

 

EXPENSES

 

 

ACTUAL COST

DEALER

NUMBER

RECORD)

OF RECORD?

 

 

 

 

 

 

 

A. Heat*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

Air Conditioning

 

4

 

 

$

 

 

 

C. Gas (for cooking, hot water)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Propane (for needs other than heat)

 

5

 

 

$

 

 

 

D. Liquid Propane Gas

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Other Utilities or Expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sewer

 

6

 

 

$

 

 

 

F. Air Conditioning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G. Utility Installation Fees

 

 

 

 

 

 

 

 

 

Trash

 

7

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H. Sewer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

I. Trash

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Utilities and Expenses

 

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J. Water

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you live in public housing?

 

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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?

 

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

NO

 

 

IF YES, AMOUNT

HOW OFTEN

LEGALLY

CHILD IN

 

 

 

 

 

 

 

 

PAID

 

OBLIGATED

SNAP HH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays child support

1

 

 

 

 

$

 

 

 

 

 

 

YES

 

NO

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays spousal support

2

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays for child care

3

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays for dependent care

4

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays tuition, fees, or other educational expenses

5

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has additional expenses (Example: car payment, car

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

insurance payment, credit card payments, other loan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

payments, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify: _______________________________

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

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?

 

 

 

 

STATUS

 

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?

 

 

 

 

 

 

 

 

 

 

and/or the Supplemental Nutrition Assistance Program

 

 

Who? ________________________________________ 10

 

 

 

 

 

 

 

 

 

 

(SNAP) because of fraud/an Intentional Program

 

 

 

 

 

 

 

 

 

 

Has your spouse ever been in the U.S. military?

11

YES

NO

 

 

Violation?

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does Client Receive

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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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

NO

 

For Board Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

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

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

2

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

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

First Name

 

 

 

 

 

 

Middle Initial

Suffix

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

Apt. No.

 

 

 

 

City/Town/Village

 

Zip Code

 

 

County

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

P.O. Box, Star Route, etc.

Post Office

 

Zip Code

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Gender (optional)

 

 

 

Telephone (optional)

 

 

 

 

 

Email (optional)

 

 

 

6

 

 

 

 

 

 

7

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The last year you voted

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

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

 

 

SAM party

 

 

 

 

12

 

• 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

 

 

 

 

 

 

 

 

 

 

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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.

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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