The LDSS-3174 form, revised in July 2020, is a critical document for individuals in New York State seeking recertification for certain benefits and services, seamlessly integrating multiple aspects of public assistance, healthcare, and nutritional aid into one streamlined process. This comprehensive form is designed to recertify eligibility for Public Assistance (PA), the Supplemental Nutrition Assistance Program (SNAP), and Medicaid (MA), ensuring that those in need can continue to access vital support services without interruption. It places a significant emphasis on inclusivity and accessibility, offering alternatives for those who are blind or seriously visually impaired, such as providing the form and subsequent communications in large print, audio CD, Data CD, or Braille. This initiative underscores the state's commitment to assisting individuals in a respectful and supportive manner, reaffirming the necessity for applicants to engage in work-related activities towards achieving self-sufficiency where applicable. Additionally, the form addresses various household changes and circumstances, ensuring a comprehensive assessment of each applicant's current situation. The form also navigates applicants through a structured recertification process, from indicating the programs for which they are applying to providing detailed household information, thereby facilitating a thorough review of their eligibility with nuanced attention to changing circumstances and ensuring that the benefits distribution process remains fair and effective.
Question | Answer |
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Form Name | Ldss 3174 Form |
Form Length | 26 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 6 min 30 sec |
Other names | how to otda ldss, get the ldss 3174 form, ldss 3174 form rev 7 16, ldss 3174 pdf |
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM
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DISPOSITION |
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EFFECTIVE DATE |
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RECERTIFICATION |
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CLOSE |
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REASON CODE |
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ELIGIBILITY DETERMINED BY (WORKER): |
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ELIGIBILITY APPROVED BY (SUPERVISOR): |
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SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY |
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INFORMATION |
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FORM __________ |
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0F _____________ |
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DATE RECEIVED BY AGENCY |
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SOCIAL SERVICES DISTRICT |
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PROVIDER AGENCY |
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EMPLOYED BY: |
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SPECIFY: |
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PA AUTHORIZATION PERIOD |
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MA AUTHORIZATION PERIOD |
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FROM |
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SNAP AUTHORIZATION PERIOD
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NEW YORK STATE RECERTIFICATION FORM FOR CERTAIN BENEFITS AND SERVICES
If you are blind or seriously visually impaired and need this recertification form 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 a recertification form in an alternative format, see the instruction book
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
Know” Books 1, 2 and 3
When you see “MA” on the recertification form, it means “Medicaid.” You may apply for MA using this recertification form only if you are also recertifying for Public Assistance or the Supplemental Nutrition Assistance Program at the same time. If you wish to only recertify for MA, you can go online at https://nystateofhealth.ny.gov/ and/or call
PAGE 1 |
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
SECTION 1 CHECK EACH PROGRAM YOU OR ANY |
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Public Assistance (PA) Supplemental Nutrition Assistance Program (SNAP) Medicaid (MA) and SNAP Medicaid (MA) and PA |
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HOUSEHOLD MEMBER ARE RECERTIFYING FOR |
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SECTION 2 |
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WHAT IS YOUR |
ENGLISH |
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DO YOU WANT TO |
ENGLISH ONLY ENGLISH AND SPANISH |
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SECTION 5 |
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PRIMARY |
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RECEIVE NOTICES IN: |
DO ANY OF THESE APPLY TO YOU? |
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LANGUAGE? |
OTHER (specify) ________ |
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SECTION 3 |
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RECIPIENT INFORMATION |
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PLEASE PRINT CLEARLY |
Pregnant |
1 |
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FIRST NAME |
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M.I. |
LAST NAME |
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MARITAL |
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Victim of Domestic Violence |
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STATUS |
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AREA CODE |
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Need to Establish Parentage |
3 |
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STREET ADDRESS |
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Need Child Support |
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Drug/Alcohol Problem |
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IN CARE OF NAME (COMPLETE IF YOU RECEIVE YOUR MAIL IN CARE OF ANOTHER PERSON) |
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Fuel or Utility Shutoff |
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No Place to Stay/Homeless |
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MAILING ADDRESS (IF DIFFERENT FROM ABOVE) |
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Fire or Other Disaster |
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IS THIS A SHELTER? |
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HAVE YOU LIVED |
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AT YOUR |
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CAN BE |
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AREA CODE |
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PRESENT ADDRESS? |
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REACHED |
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Serious Medical Problem |
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DIRECTIONS TO CURRENT ADDRESS |
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Pending Eviction |
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No Food |
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FORMER ADDRESS |
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Need Foster Care |
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IF YOU ARE CURRENTLY WITHOUT A HOME, CHECK HERE |
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Need Child Care |
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Problems with English |
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AGENCY HELPING APPLICANT/CONTACT PERSON |
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PHONE NUMBER |
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DO YOU NEED THE MEDICAID PORTION OF THIS RECERTIFICATION FORM AND THE POTENTIAL RECEIPT OF ANY MEDICAID COVERAGE TO BE KEPT CONFIDENTIAL? |
YES NO |
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LIST THE THINGS THAT HAVE CHANGED SINCE YOUR APPLICATION OR LAST RECERTIFICATION (such as moved, had a baby, income, etc.) _______________________________________________________ |
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SECTION 4 – If You Are Reapplying For SNAP: You can file a recertification form the day you get it. In order to file a SNAP recertification, it must have, at minimum, your name, address (if you have one) and signature below. You must complete the recertification process, including signing the last page of the recertification and being interviewed. If eligible, you will get SNAP benefits back to the date you filed the recertification. You must be told, within 30 days of the date you turned in (filed) your recertification for SNAP benefits, if your recertification 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 recertifying for both Supplemental Security Income (SSI) and SNAP benefits prior to leaving the institution, the filing date of the recertification is the date you leave the institution.
SNAP RECIPIENT/REPRESENTATIVE SIGNATURE
X
DATE SIGNED
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
SECTION 6 – HOUSEHOLD INFORMATION – List everybody who lives with you, even if they are not recertifying with you. List yourself on the first line.
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This person is recertifying for: |
Date of Birth: |
Sex: |
Gender Identity (Optional): |
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First Name, Middle Initial, Last Name |
(Male, Female, |
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MA |
(mm/dd/yyyy) |
(M/F) |
Transgender, Different Identity |
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to you: |
(See instruction book, |
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[please describe]) |
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or talk to your social services district) |
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01
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Line No. |
ONC |
FIRST NAME |
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M.I. |
LAST NAME |
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PLEASE LIST MAIDEN OR |
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OTHER NAMES BY WHICH |
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YOU OR ANYONE IN YOUR Line No. |
ONC |
FIRST NAME |
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M.I. |
LAST NAME |
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HOUSEHOLD HAVE BEEN |
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KNOWN |
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SECTION 7 |
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HAS ANYONE MOVED INTO THE HOUSEHOLD IN THE PAST YEAR? |
YES |
NO DID THEY EVER LIVE IN NEW |
HAS ANYONE MOVED OUT OF THE HOUSEHOLD IN THE LAST YEAR? |
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IF YES, INCIDATE BELOW. |
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YORK STATE BEFORE NOW? |
YES |
NO |
IF YES, INCIDATE BELOW. |
NAME |
NAME |
WHEN? |
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NO |
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NAME |
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NAME |
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WHEN? |
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IS ANYONE |
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IF YES, WHO |
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REASON |
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END DATE |
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SANCTIONED? |
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LEGALLY |
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RESPONSIBLE |
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CONTRIBUTION/ |
CHECK IF MEMBER |
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FIRST NAME |
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LAST NAME |
YES |
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NO |
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WHOM? |
DEEMED INCOME |
OF SNAP HOUSEHOLD |
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INDIVIDUAL EDUCATION |
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STATUS |
DATE OF |
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APPLIED FOR |
SPONSORED |
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DEGREE RECEIVED |
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DEGREE RECEIVED |
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ADJUSTED |
ENTRY/STATUS |
CITIZENSHIP |
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05 |
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02 06
03 07
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PAGE 2
YES NO
PAGE 3 |
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
LN
01
02
03
04
05
06
07
08
SECTION 8 – RACE/ETHNICITY – Providing this information is voluntary. It will not affect the eligibility of the persons recertifying or the level of benefits received. The reason for requesting this information is to ensure that program benefits are distributed without regard to race, color, or national origin.
HHISPANIC OR LATINO
INATIVE AMERICAN OR ALASKAN NATIVE
AASIAN
BBLACK OR AFRICAN AMERICAN
PNATIVE HAWAIIAN OR PACIFIC ISLANDER W WHITE
U UNKNOWN (MA ONLY)
ENTER Y (YES) OR N (NO) FOR HISPANIC OR LATINO
ENTER Y (YES) OR N (NO) FOR EACH RACE
H |
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W |
U |
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ANTICIPATED FUTURE ACTION |
CASE TYPE |
RELATED CASE NUMBERS |
CONSIDER |
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LINE NO. |
CODE |
DATE |
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Relationship |
REQUESTED |
DOCUMENTATION |
IN FILE |
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Filing Unit |
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Photo ID |
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Legally Responsible Relative |
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Birth Verification |
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Single Economic Unit |
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Marriage License |
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SNAP Household Composition |
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Social Security Card |
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SNAP Aged/Disabled Individual |
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Code 9 Resolution |
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NEEDED |
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REFERRALS |
COMPLETED |
Photo ID |
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Immigration Status |
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AFIS (PA Only)
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Legal |
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CBIC/PIN |
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Services |
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Economic Unit Questionnaire) |
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RFI/OCA |
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SSA |
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Health Insurance |
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NYSoH |
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Child Support |
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Chronic |
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Medicare Savings Program |
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DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
PAGE 4 |
Please read this entire page carefully before completing it. If you have questions, see the instruction book
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SECTION 9 – |
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SECTION 10 – CERTIFICATION |
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LIST EVERYONE WHO IS RECERTIFYING OR WHO IS REQUIRED TO RECERTIFY. |
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Some social services programs require that you certify that you are a United States citizen, Native American or |
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national of the U.S., or a |
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You MUST sign the Certification below only if you are a United States citizen, Native American or national of the |
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United States, or a |
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• Public Assistance (where there are children in the household or a member of the household is pregnant), |
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or |
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• The Supplemental Nutrition Assistance Program, or |
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• Medicaid (except if the applicant is pregnant) |
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An adult household member or authorized representative may sign for all household members. Example: A |
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parent without a satisfactory |
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NEEDED |
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REFERRALS |
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COMPLETED |
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Systematic Alien Verification for Entitlements (SAVE) |
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A recertification for SNAP must list all persons living in the SNAP household. A recertification for PA must list all children for whom you are |
SIGN* AND DATE THE BOX BELOW FOR EACH APPLICANT. |
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recertifying, 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, |
In the case of a recertifying |
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national of the U.S. or an |
status, check the program(s) for which each recertifying |
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number (Alien Registration Number) or a |
satisfactory immigration status. (See the instruction book, |
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Statewide.) |
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of the household will receive reduced benefits. If you are a Native American, check citizen/national. |
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Check either "CITIZEN / NATIONAL" or |
USCIS NUMBER (ALIEN REGISTRATION |
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DATE |
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FIRST NAME |
MI |
LAST NAME |
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NUMBER) OR |
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CERTIFICATION |
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for each person. |
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(If Applicable) |
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01 |
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CITIZEN/ |
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NATIONAL |
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02 |
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CITIZEN/ |
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Sign Name |
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NATIONAL |
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03 |
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CITIZEN/ |
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Sign Name |
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NATIONAL |
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04 |
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CITIZEN/ |
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Sign Name |
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NATIONAL |
X |
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05 |
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CITIZEN/ |
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Sign Name |
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NATIONAL |
X |
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06 |
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CITIZEN/ |
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Sign Name |
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NATIONAL |
X |
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07 |
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CITIZEN/ |
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Sign Name |
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NATIONAL |
X |
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08 |
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CITIZEN/ |
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Sign Name |
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NATIONAL |
X |
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By checking a box above and by signing the certification form in Section 10, 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
I understand that signing the above Certification may result in information about recertifying members of my household being submitted to the United States Citizenship and Immigration Services for verification of
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, and Medicaid.
*A person who wishes to sign the Recertification Form 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 RECERTIFICATION FORM |
SECTION 11 – INFORMATION REGARDING REFERRAL TO THE CHILD SUPPORT ENFORCEMENT UNIT
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If you are recertifying for Medicaid in addition to Public Assistance or the Supplemental Nutrition Assistance Program, you may have to help |
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REQUESTED |
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DOCUMENTATION |
IN FILE |
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us obtain medical support for yourself and your recertifying children. Answer the following questions to determine if you need to complete this |
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Acknowledgment of Parentage |
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section. Include yourself, as appropriate: |
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or Paternity |
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Child Support Order |
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1. |
Are you recertifying for an individual under the age of 21 who was born out of wedlock and for whom legal parentage has not been |
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Good Cause Form |
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established? Yes |
No |
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Yes |
No |
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Death Certificate |
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2. |
Are you recertifying for an individual under the age of 21 who has an absent parent (noncustodial parent)? |
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Divorce Decree |
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You do not need to complete this section if you answered “No” to both of these questions. Go to the next section. |
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VA Benefits |
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Order of |
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You must complete this section if you answered “Yes” to either or both of these questions. Provide the names of all individuals under |
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Filiation/Paternity/Parentage |
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Birth Certificate |
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the age of 21 for whom you are recertifying and any information you currently have about those individuals’ noncustodial parents or alleged |
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NEEDED |
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REFERRALS |
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COMPLETED |
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parents. |
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CTHP |
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3. |
Are you under the age of 21? Yes |
No |
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CAP |
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Referral for Child Support |
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If you answered “Yes” to this question, provide the information for your noncustodial parent(s) or alleged parent(s). |
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Services |
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Parentage/Paternity |
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As a condition of obtaining assistance, you are required to assign certain rights related to support, as described in the Notices, Assignments, |
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CONSIDER |
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Health Insurance of Non- |
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Authorizations, and Consents section at the end of this recertification. You will be provided with the |
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Child Health Plus |
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Support Services,” to complete and return to the Child Support Enforcement Unit. Except in situations of domestic violence or other good |
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custodial Parent/Absent |
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TASA |
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Spouse |
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cause, as a condition of obtaining assistance, you are required to cooperate with the Child Support Enforcement Unit to locate any |
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noncustodial parent or alleged parent; establish legal parentage for each individual under the age of 21 born out of wedlock; and establish, |
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Petition to Family Court |
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SSI/SSA |
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modify, and/or enforce orders of support. You also will be provided with the |
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Support,” which explains your responsibilities and your rights if you do not cooperate with the Child Support Enforcement Unit. |
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NONCUSTODIAL PARENT |
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NAME OF INDIVIDUAL UNDER AGE 21 |
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NONCUSTODIAL PARENT OR ALLEGED PARENT’S NAME AND ADDRESS |
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OR ALLEGED PARENT’S |
NONCUSTODIAL PARENT OR |
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DATE OF BIRTH |
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ALLEGED PARENT’S |
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SOCIAL SECURITY NUMBER |
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MONTH |
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YEAR |
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A. |
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B. |
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C. |
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D. |
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E. |
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DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
PAGE 6 |
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SECTION 12 – TAX FILING/DEPENDENT STATUS - Please select the tax status for each individual living in the household. |
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TAX STATUS |
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FIRST NAME |
MIDDLE |
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LAST NAME |
SINGLE |
MARRIED |
MARRIED |
HEAD OF |
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QUALFIYING |
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DEPENDENT |
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WILL NOT BE |
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INITIAL |
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FILING |
FILING |
HOUSEHOLD |
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WIDOW(ER) |
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AND WILL BE |
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FILING TAXES |
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JOINTLY |
SINGLE |
(WITH |
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FILING TAXES |
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QUALIFYING |
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DEPENDENT |
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INDIVIDUAL) |
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CHILD |
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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 |
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can skip this question. |
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NAME OF TAX DEPENDENT |
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NAME OF TAX FILER |
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FIRST NAME |
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MIDDLE INITIAL |
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LAST NAME |
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FIRST NAME |
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MIDDLE INITIAL |
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LAST NAME |
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SECTION 13 – ABSENT/DECEASED SPOUSE INFORMATION – If the spouse of anyone recertifying lives someplace else or is deceased, please indicate below.
NAME OF PERSON RECERTIFYING 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 14 – ABSENT CHILD INFORMATION – If anyone recertifying has a child under the age of 21 living someplace else, please indicate below.
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ADDRESS OF CHILD (STREET, CITY, |
LEGAL PARENTAGE ESTABLISHED? |
DO YOU PAY CHILD SUPPORT? |
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NAME OF PERSON |
NAME OF ABSENT CHILD |
DATE OF BIRTH |
COUNTY, STATE, AND ZIP CODE) |
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RECERTIFYING |
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Yes |
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No |
Yes |
No |
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SECTION 15 – TEEN PARENT INFORMATION |
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TEEN PARENT |
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TEEN PARENT CHILDREN |
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Is there a parent under the age of 18 (“teen parent”) in the household? Yes |
No |
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LN NO. |
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Marital Status |
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LN NO. |
__________________ |
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High School Diploma/High School Equivalent? |
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Name ________________________________________________ |
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LN NO. _____________________ |
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LN NO. |
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Marital Status |
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High School Diploma/High School Equivalent? |
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Does the teen parent’s child live in the household? Yes |
No |
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Name of teen parent’s child _______________________________________________ |
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PAGE 7 |
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
SECTION 16 – INCOME INFORMATION: |
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Indicate if you or anyone who lives with you receives money from: |
YES |
NO |
WHO |
AMOUNT/VALUE & |
WHO |
AMOUNT/VALUE & |
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INCOME |
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FREQUENCY |
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FREQUENCY |
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Unemployment Insurance Benefits |
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LN |
SOURCE |
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1 |
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No. |
CODE |
AMOUNT |
PERIOD |
Supplemental Security Income (SSI) Benefits (State and Federal |
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Total) |
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2 |
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Social Security Disability (SSD) Benefits |
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3 |
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Social Security Dependent Benefits |
4 |
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Social Security Survivor’s Benefits |
5 |
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Social Security Retirement Benefits |
6 |
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Railroad Retirement Benefits |
7 |
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Retirement Benefits (Pensions) |
8 |
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Dividends/Interest from Stocks, Bonds, Savings, etc. |
9 |
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Workers’ Compensation |
10 |
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NYS Disability Benefits |
11 |
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Veteran’s Pension/Benefits/Aid and Attendance |
12 |
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Public Assistance Grant |
13 |
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GI Dependency Allotments |
14 |
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Education Grants or Loans |
15 |
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Contributions/Gifts (Received) |
16 |
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Foster Care Payments (Received) |
17 |
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Child Support Payments (Received) |
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CONSIDER |
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Received From:________________________________________ |
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Child Support |
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18 |
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Spousal Support (Received) |
19 |
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Explained Budgeted |
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SNAP Aged/Disabled Indicator |
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Private Disability Insurance - Health/Accident Insurance Policy |
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Disability Review |
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Income |
20 |
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Reception |
and Placement Grant (SNAP Only) |
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21 |
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Union Benefits (including Strike Benefits) |
22 |
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Refugee Matching Grant |
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Change in Income from Last Budget |
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Loans, Other than Education (Received) |
23 |
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Income from a Trust (including income you are currently entitled to |
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receive, or were entitled to receive in the past, that has not been |
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distributed) |
24 |
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Training Allotments/Stipends |
25 |
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Rental Income (Received) |
26 |
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Boarders/Lodgers Income (Received) |
27 |
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Other
Income
(Please
Specify)
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DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
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Deductions: Certain types of Medicaid budgeting allow |
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applicants/recipients to reduce their countable income with deductions |
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that they take on their federal taxes. These are specific expenses that |
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AMOUNT/VALUE & |
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AMOUNT/VALUE & |
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the Internal Revenue Service (IRS) allows people to deduct to reduce |
YES |
NO |
WHO |
WHO |
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FREQUENCY |
FREQUENCY |
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their taxable income. Only record deductions here if you will claim them |
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on the current year’s tax return. |
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Educator expenses |
1 |
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Individual Retirement Account (IRA) deduction |
2 |
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Student loan interest deduction |
3 |
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Tuition and fees |
4 |
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Certain business expenses (reservists, artists, |
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officials) |
5 |
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Health savings account deduction |
6 |
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7 |
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Deductible part of |
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S/E, SIMPLE & qualified plans |
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S/E health insurance deduction |
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Penalty on early withdrawal of savings |
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Alimony paid |
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Domestic production activities deduction |
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Additional adjustments added on line 36 (IRS Form 1040 only) |
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Archer MSA deduction |
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Other Adjustment |
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(Please Specify) |
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PAGE 8
SECTION 17 –
IMMIGRATION STATUS SPONSOR INFORMATION
Answer all questions listed below.
YES |
NO |
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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
NAME OF SPONSOR: |
PHONE NO.: |
NEEDED |
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REFERRAL |
UIB
COMPLETED
ADDRESS:
PAGE 9 |
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DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
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SECTION 18 – EMPLOYMENT INFORMATION |
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I am currently: |
employed |
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unemployed |
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Gross Income $ ________________ |
Hours Worked Monthly _________________ |
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REQUESTED |
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DOCUMENTATION |
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IN FILE |
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(Include wages, salary, overtime pay, |
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CINTRAK/RFI/IRCS |
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commissions, and tips) |
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1099 |
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Paid: Weekly |
Biweekly |
Monthly |
Day of the week paid: |
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Employment Verification |
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Employer’s Name and Address: |
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1 |
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Income Tax Return |
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______________________________________________ |
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Phone No. __________________ |
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______________________________________________ |
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Wage Stubs |
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Is anyone else who lives with you currently: |
employed |
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Work Registration Form |
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Dependent/Child Care Form/Statement |
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Who: _________________________________________________ |
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Approval of Informal Child Care Provider |
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Gross Income $ ________________ |
Hours Worked Monthly _________________ |
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Paid: Weekly |
Biweekly |
Monthly |
Day of the week paid: |
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2 |
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Employer’s Name and Address: |
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______________________________________________ |
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Phone No. __________________ |
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NEEDED |
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REFERRALS |
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COMPLETED |
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CONSIDER |
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Limited English Proficiency |
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______________________________________________ |
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CAP |
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Earned Income Tax Credit (see |
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Disability |
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Explaining Periodic Reporting Requirements |
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Employment |
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Net Loss of Cash Income |
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Is health insurance available through your employer? |
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Yes |
No |
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TPHI/COBRA |
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P.A.S.S. Income Amount and Sources |
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Does anyone who lives with you have health insurance with an employer? |
Yes |
No |
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UIB |
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Employment Sanctions |
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Who: _________________________________________ |
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3 |
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Temporary Employment |
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Workers’ Compensation |
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Disability Review |
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Name of Insurance Company: _________________________________________________________ |
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Drug/Alcohol |
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Individual Development Account (IDA) |
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Domestic Violence |
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Voluntary Quit |
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Do you or anyone who lives with you have a child or dependent care |
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Yes |
No |
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Refugee Cash Assistance |
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expenses due to employment? |
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Who: _________________________________________ |
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4 |
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Do you or anyone who lives with you have other |
Yes |
No |
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expenses? |
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Who: _________________________________________ |
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5 |
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DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
PAGE 10 |
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If not employed, when was the last time you or anyone who lives with you worked? |
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Who: _________________________________________ |
When: __________________________ |
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Where: __________________________________________________________________________ |
6 |
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Why did you (or they) stop working? ___________________________________________________ |
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Did you or anyone living with you file for unemployment? |
Yes |
No |
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If yes, who? _______________________ |
When?: ________________ |
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Status of filing: Approved Denied Pending |
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Are you or is anyone who lives with you participating in a strike? |
Yes |
No |
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Who: _________________________________________ |
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7 |
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When the strike began: ___________________________ |
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Are you or is anyone who lives with you a migrant or seasonal farm |
Yes |
No |
|
||
worker? |
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Who: _________________________________________ |
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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: _____________________________________________________________
_____________________________________________________________
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9 |
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Could you accept a job today? |
Yes |
No |
10 |
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If not, why? ________________________________________________________________________ |
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What type of work would you like to do? _________________________________________ |
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_________________________________________________________________________________ |
11 |
CHILD/DEPENDENT CARE EXPENSES
|
Who Pays |
Amount |
Name |
Age |
Care Provider |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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PAGE 11 |
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
SECTION 19 – EDUCATION/TRAINING |
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What is your highest level of education completed? |
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__ Less than high school diploma |
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REQUESTED |
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DOCUMENTATION |
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IN FILE |
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If so, last grade completed? ______ |
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School Attendance |
Verification |
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__ Completion of an Individualized Education Plan (IEP) |
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__ High school diploma or General Equivalency Diploma (GED) or Test Assessing Secondary Completion (TASC™) |
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Educational Grant |
Worksheet |
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__ Associate’s Degree |
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Child Care Statement |
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__ Bachelor’s Degree |
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Does anyone else in the household have a high school diploma, General Equivalency |
Yes |
No |
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Diploma (GED) or Test Assessing Secondary Completion (TASC™), or higher level of |
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education? |
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If yes, who: _______________ |
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Degree attained:_________________ |
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NEEDED |
REFERRALS |
COMPLETED |
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2 |
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Supportive Services |
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Date completed: _________________ |
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Indicate if you or anyone who lives with you who is recertifying for or getting assistance: |
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Is or has been in any training program in the last 12 months? |
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CONSIDER |
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YES |
NO |
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Who |
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Does anyone 18 through 49 who is attending college |
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Where |
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3 |
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meet the SNAP student eligibility requirement? |
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Does anyone pay for child or dependent care to attend school or |
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Program |
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training? |
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Is there a |
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Dates attended ________________________________ |
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equivalency diploma and who is not attending school? |
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Is anyone in training? |
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Dates completed _______________________________ |
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Are any other supportive services appropriate? |
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Is 16 years of age or older and is attending school or college? |
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Yes |
No |
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Are there any training related expenses? |
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Who |
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4 |
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Where |
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Is getting a Training Allowance? Yes |
No |
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5 |
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Who _________________________________________ |
Amt. $ |
___ |
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Is getting Educational Grants or Loans? |
Yes |
No |
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6 |
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Who ________________________________________ |
Amt. $ _______________ |
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Is under 16 years of age and is attending school? |
Yes |
No |
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7 |
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Who |
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Who |
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School |
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School |
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Who |
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School |
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School |
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DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
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PAGE 12 |
|||||
SECTION 20 – RESOURCES INFORMATION |
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Indicate if you or anyone who lives with you who is recertifying: |
YES |
NO |
WHO |
IF YES, AMOUNT/VALUE |
WHO |
IF YES, |
NEEDED |
|
REFERRAL |
COMPLETED |
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AMOUNT/VALUE |
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Has cash available |
1 |
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$ |
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$ |
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Legal |
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Has a checking account(s) |
2 |
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Resource |
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Has a savings account(s) or certificate(s) of deposit |
3 |
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Has a credit union account(s) |
4 |
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Has life insurance |
5 |
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Has title or registration to a motor vehicle(s) |
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LIFE INSURANCE |
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or other vehicle(s): |
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FACE AMOUNT |
CASH VALUE |
||
Year ________ Make/Model ____________________________ |
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Year ________ Make/Model ____________________________ |
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Other______________________________________________ 6 |
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Has stocks, bonds, certificates or mutual funds |
7 |
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Has savings bonds |
8 |
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Has an IRA, Keogh, 401(k) or deferred compensation account(s) |
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9 |
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Has an irrevocable burial trust |
10 |
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Has a burial fund |
11 |
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REQUESTED |
DOCUMENTATION |
IN FILE |
Has a burial space |
12 |
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Resource Checklist |
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Has their own home |
13 |
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Market Value |
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Has real estate, including |
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DMV Clearance |
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14 |
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Bank Statement |
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Is eligible for an income tax refund |
15 |
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Assignment |
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of Proceeds |
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Has an annuity |
16 |
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Car/Vehicle |
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Title |
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Is the beneficiary of a trust |
17 |
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Car/Vehicle |
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Registration |
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(Older Models) |
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Expects to receive a trust fund, lawsuit settlement, inheritance or |
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Bank Clearance |
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income from any other sources |
18 |
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Has an “in trust” account(s) |
19 |
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RFI/OCA |
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1099 |
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Has a safe deposit box(es) |
20 |
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Has resources other than those listed above |
21 |
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Has anyone (including your spouse, even if not recertifying or |
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living with you) given away any cash, or sold/transferred any real |
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estate, income or personal property in the past 36 months? |
22 |
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CONSIDER |
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|||||
Has anyone (including your spouse, even if not recertifying or |
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Children’s Resources |
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|||||
living with you) ever created a trust in the past or transferred any |
|
|
|||||||||||||
|
|
Lump Sum |
|
|
|
||||||||||
assets to a trust within the past 60 months? |
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||||||||
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|
Boats, Campers, Snowmobiles |
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|
|||||
If yes, when? _______________________________________23 |
|
|
|||||||||||||
|
|
Individual Development Account (IDA) |
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VEHICLE INFORMATION |
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Exempt Vehicles |
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|
EXEMPT |
|
|
||||
YR. |
MAKE |
MODEL |
OWNER’S NAME |
AMOUNT OWED |
NADA VALUE |
LIEN HOLDER |
ACCOUNT NO. |
|
EIC |
|||
YES* |
NO |
|||||||||||
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$ |
$ |
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|
Change in Resources from Last Budget |
$ |
$ |
*IF EXEMPT, WHY?
PAGE 13 |
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
SECTION 21 – MEDICAL INFORMATION |
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|
|
REQUESTED |
DOCUMENTATION |
IN FILE |
|
|
|
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|
|
|
|
|
|
Pregnancy Statement |
|
|
Indicate if you or anyone who lives with you who is recertifying: |
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|
|
YES |
NO |
IF YES, WHO |
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|
Med/Psych Statement |
|
|
Has any medical bills or |
1 |
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|
|
Drug/Alcohol Screening |
|
||
Is on Medicaid with a |
2 |
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|
|
Drug/Alcohol Statement |
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|
|
Paid or Unpaid Medical Bills |
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|
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|
|
|
POLICY NO.: |
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|
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|
|
Has health or hospital/accident insurance (including insurance |
|
|
|
|
AMOUNT: |
|
|
|
|
SSI Application Verification (PA ONLY) |
|
from employer) |
3 |
|
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|
||
|
|
|
FREQUENCY OF PAYMENT: |
|
|
|
|
CONSIDER |
|
||
|
|
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|
|
|
|
|
AD/SSI Related |
|
||
Has health insurance available through an employer |
4 |
|
|
|
INSURANCE COMPANY NAME: |
|
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|
|||
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|
|
SNAP Aged/Disabled Indicator |
|
||||
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|||||
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|||
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|
|
WHO IS COVERED: |
|
|
|
SNAP Medical Deduction |
|
|
Has Medicare (red, white, and blue card) |
5 |
|
|
|
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|
||||
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|
|
TPHI Reimbursement |
|
||||
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|||||
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|
|
EFFECTIVE DATE: |
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|
||
Has a health attendant/home health aide |
6 |
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||||
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|
|
Kreiger |
|
||||
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|
|
Domestic Violence |
|
|
Is blind, sick or disabled |
7 |
Is the answer to question 7 in this section consistent |
|
SSI Referral |
|
|
Is a child with a developmental disability |
8 |
with Section 18 asking if the applicant or any other adult |
|
Earned Income Credit |
|
|
who lives in the household have any medical conditions |
|
|||||
|
|
that limit their ability to work or the type of work that |
|
Change in Resources |
|
|
|
|
they can perform? |
NEEDED |
REFERRALS |
COMPLETED |
|
|
|
|
||||
Is in a hospital, nursing home or other medical institution |
9 |
|
|
|
SSI |
|
Has paid or unpaid medical bills within 3 months preceding |
|
|
|
|
Disability Interview |
|
the month of this recertification |
10 |
|
|
|
Medical Report |
|
Is or was drug or alcohol dependent |
11 |
|
|
|
Disability Report |
|
Needs home care/personal care |
12 |
|
|
|
AD |
|
|
|
|
|
|
||
Is on SSI or has ever applied for SSI |
13 |
|
|
|
TPHI |
|
|
|
|
|
|||
Is pregnant |
|
|
|
|
|
|
|
|
|
|
CTHP |
|
|
If pregnant, due date: _____________________________ |
14 |
|
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|
|
Family Planning |
|
||
Expected number of births: _________________________ |
|
|
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|
|
Receives treatment from a drug abuse or alcohol treatment |
|
|
|
|
SSA (RSDI) |
|
|
|
|
|
|
|
|
program |
15 |
|
|
|
Veteran’s Benefits |
|
Has not been able to work for at least 12 months because of |
|
|
|
|
Veteran’s Counseling |
|
|
|
|
|
|
|
|
a disability or illness |
16 |
|
|
|
Child Health Plus |
|
Has daily activity limited because of a disability or illness that |
|
|
|
|
COBRA Eligibility |
|
|
has lasted or will last at least 12 months |
17 |
|
|
|
Nurse’s Aide Service |
|
|
Has been in a car accident or |
|
|
Home Care |
|
|
||
years |
18 |
|
|
|
NYSoH |
|
|
Has had a government agency (public program) besides Medicaid |
|
|
|
|
|||
or Medicare pay any of your medical bills |
|
|
|
|
|
|
|
If yes, what agency _____________________ |
19 |
|
|
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|
|
|
|
|
|
|
|
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 |
|
|
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|
|
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
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
|
|
|
|
|
|
|
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) |
||||
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|||||||
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provider) |
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|
SECTION 22 – SHELTER |
|
|
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|
||
|
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|
|
|
|||
WHAT IS YOUR LANDLORD’S NAME? |
|
|
|
|
SHELTER |
MONTHLY |
|
|||
|
|
|
|
|
|
|
COSTS |
ACTUAL COST |
|
|
______________________________________________________________________ |
|
|
A. Room and Board |
|
|
|
||||
|
|
B. Rent |
|
|
|
|||||
|
|
|
|
|
|
|
|
|||
WHAT IS YOUR LANDLORD’S ADDRESS? |
|
|
|
|
||||||
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C. Trailer Lot Rent |
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_______________________________________________________________________ |
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D. Mortgage Payment |
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1. |
Principal |
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_______________________________________________________________________ |
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2. |
Interest |
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3. |
Property Tax |
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_______________________________________________________________________ |
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(including |
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School Tax) |
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WHAT IS YOUR LANDLORD’S PHONE NUMBER? |
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4. |
Homeowner’s |
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( ) _________________________________________________________ |
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Insurance |
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(incl. Fire |
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YES |
NO |
IF YES, |
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Insurance) |
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AMOUNT |
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5. |
Taxes |
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Included |
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Do you or anyone who lives with you have a rent, mortgage or |
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$ |
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in Mortgage |
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(Escrow |
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other shelter expense? |
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Payment) |
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Do you or anyone who lives with you have a heat bill separate |
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$ |
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6. |
Assessments |
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(Sewer, etc.) |
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from your rent or other shelter expense? |
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E. Total Mortgage |
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Payment (Line |
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TOTAL |
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(Lines A - E) |
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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
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 RECERTIFICATION FORM |
SECTION 22 – SHELTER (CONT.) |
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Do you or anyone who lives with you have the following |
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YES |
NO |
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IF YES, |
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expenses separate from your rent or other shelter expense? |
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AMOUNT |
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Electricity (for needs other than heat; example: lights, cooking, |
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$ |
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hot water, etc.) |
1 |
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Natural Gas (for needs other than heat; example: cooking, hot |
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$ |
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water, etc.) |
2 |
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IN WHOSE NAME IS |
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THE BILL? |
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MONTHLY |
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MONTHLY |
NAME OF |
ACCOUNT |
(CUSTOMER OF |
WHO IS THE TENANT |
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Water |
3 |
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$ |
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EXPENSES |
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ACTUAL COST |
DEALER |
NUMBER |
RECORD) |
OF RECORD? |
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A. Heat* |
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B. Electricity (for cooking, lights, hot water) |
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Air Conditioning |
4 |
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$ |
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C. Gas (for cooking, hot water) |
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Propane (for needs other than heat) |
5 |
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$ |
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D. Liquid Propane Gas |
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E. Other Utilities or Expenses |
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Sewer |
6 |
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$ |
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F. Air Conditioning |
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G. Utility Installation Fees |
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Trash |
7 |
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$ |
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H. Sewer |
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$ |
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I. Trash |
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Other Utilities and Expenses |
8 |
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J. Water |
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Specify __________________ |
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Do you live in public housing? |
9 |
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Do you live in Section 8, HUD, or other subsidized housing? 10 |
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*Check Primary Heat Type: |
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Do you live in a drug/alcohol treatment facility? |
11 |
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Natural Gas |
Oil |
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PSC Electric |
Coal |
Other ________________________ |
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Kerosene |
Propane |
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Municipal Electric |
Wood |
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ADDITIONAL INFORMATION |
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SECTION 23 – OTHER EXPENSES |
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Indicate if you or anyone who lives with you who is |
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YES |
NO |
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IF YES, AMOUNT |
HOW |
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LEGALLY |
CHILD IN |
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OFTEN |
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OBLIGATED |
SNAP HH |
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recertifying: |
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PAID |
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Pays child support |
1 |
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$ |
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YES |
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NO |
YES |
NO |
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Pays spousal support |
2 |
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$ |
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Pays for child care |
3 |
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$ |
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Pays for dependent care |
4 |
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$ |
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Pays tuition, fees, or other educational expenses |
5 |
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$ |
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Has additional expenses (Example: car payment, car |
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$ |
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insurance payment, credit card payments, other loan |
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payments, etc.) |
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Specify: _______________________________ |
6 |
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Do you or anyone who lives with you who is recertifying |
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YES |
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NO |
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owe at least four months of support for a child under the |
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age of 21? |
7 |
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DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
PAGE 16 |
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SECTION 24 – OTHER INFORMATION |
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Do you buy or plan to buy meals from a home |
YES |
NO |
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delivery or communal dining service? |
8 |
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Are you able to cook or prepare meals at home? |
9 |
YES |
NO |
VETERAN |
VETERAN |
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|
STATUS |
CODE |
NEEDED |
REFERRALS |
COMPLETED |
CONSIDER |
||
Have you or anyone in your household ever been in the U.S. military? |
YES |
NO |
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|
|
Services |
SNAP Dependent Care Deductions |
||
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Who? ________________________________________ |
10 |
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UIB |
District of Fiscal Responsibility (SSL |
|||
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62.5) |
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Has your spouse ever been in the U.S. military? |
11 |
YES |
NO |
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Is anyone in your household a dependent of someone who is or was |
YES |
NO |
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REQUESTED |
DOCUMENTATION |
IN FILE |
||
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Child/Dependent Care |
|
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in the U.S. military? |
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Statement |
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Who? ________________________________________ |
12 |
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Recoupments |
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Indicate if you or anyone who lives with you who is recertifying: |
YES |
NO |
WHO |
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Outstanding Overpayment |
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Have you or anyone who lives with you who is recertifying moved into |
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Pending Disqualification |
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this county from another New York State county within the past two |
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months? |
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Have you or anyone who lives with you ever been found guilty of |
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and/or been disqualified for Public Assistance and/or the |
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IF TOTAL EXPENSES (INCLUDING EXPENSES NOT USED IN THE BUDGET DETERMINATION) |
||||||||||
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|
EXCEED INCOME (INCLUDING PA GRANT), EXPLORE HOW THE HOUSEHOLD IS MEETING ITS |
|||||||||||
Supplemental Nutrition Assistance Program (SNAP) because of |
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|||||||||||
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OBLIGATIONS. |
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|
|||
fraud/an Intentional Program Violation? |
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CONSIDER |
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Have you or anyone who lives with you received benefits for which |
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|
|
Actual Expenses |
|
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|
|
Actual Expenses, including: shelter, |
||||
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|
$ |
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|||||||
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fuel/utility costs, telephone costs, etc. |
|||||||
they were not entitled, which have not been fully repaid to this or |
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Actual Shelter |
||||
another agency? |
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Actual Fuel/Utility Costs |
||||
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Telephone Expenses |
|||
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$ |
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||
Have you or any member of your household been convicted of making |
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|
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Actual Income |
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fraudulently receiving duplicate SNAP Benefits in any state after |
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September 22, 1996? |
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Does Client Receive Contribution Towards Difference |
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If Yes, From Whom? __________________________ |
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Have you or any member of your household been convicted of buying |
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or selling SNAP Benefits for a combined amount of over $500 or more |
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after September 22, 1996? |
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Based on the information contained in this recertification, make sure you reconsider the |
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Are you or any member of your household fleeing to avoid |
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prosecution, custody or confinement after conviction of a felony or |
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Are you or any member of your household violating probation or |
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Category is _____________________________________________ |
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PROPERTY TRANSFER STATUS |
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Documented by _________________________________________ |
I have I have not sold, transferred or given away any of my property to anyone to get Public
Assistance or SNAP Benefits.
PAGE 17 |
DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM |
NOTES/COMMENTS
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
With respect to all other programs for which this recertification 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
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 recertification, 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.
PAGE 18 |
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)
To file a Supplemental Nutrition Assistance Program (SNAP) complaint of discrimination, complete the USDA Program Discrimination Complaint Form,
(1) Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C.
(2)Fax: (202)
(3)Email: program.intake@usda.gov.
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800)
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
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,
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 recertifying 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 recertification, 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/recertification 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.
PAGE 19 |
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 needs, residency/address, living arrangements, household size, income, employment, property/resources, dependent care costs, health insurance,
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 recertify 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 recertification 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 recertified 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 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
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
•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.
PAGE 20 |
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
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to recertify 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 recertification. 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 recertification, 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
PAGE 21 |
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 |
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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
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
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
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 recertification is made. In addition, I will assist in making any assigned benefits available to the social services district to whom this recertification 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.
PAGE 22 |
•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
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 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
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.
PAGE 23 |
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 recertification 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 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)
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 |
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AUTHORIZED REPRESENTATIVE |
DATE SIGNED |
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ONLY COMPLETE THE FOLLOWING IF YOU WANT TO CLOSE YOUR CASE FOR ONE OR MORE PROGRAMS.
I REQUEST THAT MY CASE BE CLOSED FOR:
Public Assistance Supplemental Nutrition Assistance Benefits Medical Assistance I understand that I may reapply at any time.
Give Reason:
Signature x |
Date _______________________________ |
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NYS
“If you are not registered to vote where you live now, would you |
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Important! |
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like to apply to register here today?” |
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Applying to register or declining to register to vote will not affect the |
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If you checked YES, please complete the |
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If you do not check |
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amount of assistance that you will be provided by this agency. |
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any box, you will |
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VOTER REGISTRATION APPLICATION below |
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If you would like help filling out the voter registration application form, |
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be considered to |
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NO because I choose not to register OR |
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have decided not |
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we will help you. The decision whether to seek or accept help is yours. |
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I am already registered at my current address OR |
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You may fill out the application form in private. |
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at this time. |
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Información en español: si le interesa obtener este formulario en español, |
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I asked for and received a mail registration form |
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LLAME AL |
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中文資料:若您有興趣索取中文資料表格,請電: |
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한국어: 한국어 한국어 양식을 원하시면 |
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Signature |
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Date |
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으로 전화 하십시오. |
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যিদ আপিন এই ফর্মিট বাংলা ভাষায় চান , তাহেল |
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Please Print Name |
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VOTER REGISTRATION APPLICATION (instructions on back) |
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Yes, I need an application for an Absentee Ballot |
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Please print or type in blue or black ink |
Yes, I would like to be an Election Day worker |
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Are you a U.S. citizen? |
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A) Will you be 18 years old on or before election day? |
YES |
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For Board Use Only |
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B) Are you at least 16 years of age and understand that you must be 18 |
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YES |
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NO |
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years of age on or before election day to vote, and that until you will |
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be eighteen years of age at the time of such election your registration |
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will be marked “pending” and you will be unable to cast a ballot in any |
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If you answered NO, do not complete this form |
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election? |
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YES |
NO |
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If you answered NO to both of the prior questions, you cannot register to vote. |
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Last Name |
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First Name |
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Address where you live (do not give P.O. box) |
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Apt. No. |
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City/Town/Village |
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Address where you get your mail (if different than above) |
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P.O. Box, Star Route, etc. |
Post Office |
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Date of Birth |
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Gender (optional) |
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Telephone (optional) |
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Email (optional) |
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The last year you voted |
Your address was (give house number, street and city) |
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ID Number (Check the applicable box and provide your number) |
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New York State DMV number |
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In county/state |
Under the name (if different from your name now) |
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Last four digits of your Social Security number |
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I do not have a New York State DMV or Social Security number |
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Political Party |
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Affidavit: I swear or affirm that |
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• I am a citizen of the United States. |
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I wish to enroll in a political party |
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• I will have lived in the county, city or village for at least 30 days before |
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Democratic party |
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Libertarian party |
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the election. |
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Republican party |
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Independence party |
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• I will meet all requirements to register to vote in New York State. |
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Conservative party |
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SAM party |
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• This is my signature or mark on the line below. |
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Working Families party |
Other |
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• The above information is true, I understand that if it is not true, I can be |
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Green party |
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convicted and fined up to $5,000 and/or jailed for up to four years. |
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I do not wish to enroll in any political party and wish to be an independent voter |
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No party |
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Signature or Mark in ink |
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Date |
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(Optional) Register to donate your organs and tissues
Last Name
First Name |
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Middle Initial |
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Suffix |
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Address |
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Apt Number |
City/Town/Village |
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Birth Date |
Gender |
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Eye Color |
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DMV or ID NYC Number |
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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
/ /
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;
•
To Register You Must:
•be a U.S. citizen;
•be 18 years old (you may
•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
Telephone:
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
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