Ldss 3174 Form PDF Details

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.

QuestionAnswer
Form NameLdss 3174 Form
Form Length26 pages
Fillable?No
Fillable fields0
Avg. time to fill out6 min 30 sec
Other nameshow to otda ldss, get the ldss 3174 form, ldss 3174 form rev 7 16, ldss 3174 pdf

Form Preview Example

LDSS-3174 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

CENTER/

INTERVIEW DATE

UNIT ID

 

 

WORKER ID

 

 

CASE TYPE

CASE NUMBER

 

 

 

 

 

 

 

DISTRICT

CATEGORY

LANG

 

 

NUMBER

 

 

OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REUSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDICATOR

 

 

CASE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISPOSITION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EFFECTIVE DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECERTIFICATION

 

 

CLOSE

 

REASON CODE

 

 

ELIGIBILITY DETERMINED BY (WORKER):

DATE

 

ELIGIBILITY APPROVED BY (SUPERVISOR):

 

DATE

 

 

 

SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM __________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0F _____________

x

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE RECEIVED BY AGENCY

 

 

 

 

 

 

 

 

 

SOCIAL SERVICES DISTRICT

 

 

PROVIDER AGENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYED BY:

 

 

 

 

 

 

 

SPECIFY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PA AUTHORIZATION PERIOD

 

 

MA AUTHORIZATION PERIOD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

TO

 

FROM

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SNAP AUTHORIZATION PERIOD

FROM

 

TO

 

 

 

 

 

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 (PUB-1313 Statewide), available at www.otda.ny.gov or https://www.health.ny.gov/.

If you are blind or seriously visually impaired, would you

like to receive written notices in an alternative format? Yes

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

No

Data CD

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

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

We are committed to assisting and supporting you in a professional and respectful manner. You are responsible for participating in activities, including work activities for Public Assistance and the Supplemental Nutrition Assistance Program, where required, so you can become self-sufficient. Whenever you see “Public Assistance” or “PA” on the recertification form, it means “Family Assistance” and/or “Safety Net Assistance.” We call both programs “Public Assistance.” These PA programs are meant to assist you only until you can fully support yourself and your family. Please refer to the instruction book (PUB-1313 Statewide) and “What You Should

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

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 1-855-355-5777 for more information or to recertify, or you may use the MA-only paper application - Form DOH-4220, which your worker can give you, or call MA help line at 1-800-541-2831. If you want to recertify only for the Medicare Savings Program (MSP), you must apply with Form DOH-4328, which your worker can provide to you. If you have an immediate need for personal care services, you should apply for MA separately using the DOH- 4220 MA application form.

PAGE 1

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

LDSS-3174 Statewide (Rev. 07/20)

SECTION 1 CHECK EACH PROGRAM YOU OR ANY

 

Public Assistance (PA) Supplemental Nutrition Assistance Program (SNAP) Medicaid (MA) and SNAP Medicaid (MA) and PA

 

 

HOUSEHOLD MEMBER ARE RECERTIFYING FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHAT IS YOUR

ENGLISH

 

SPANISH

 

DO YOU WANT TO

ENGLISH ONLY ENGLISH AND SPANISH

 

SECTION 5

 

 

PRIMARY

 

 

RECEIVE NOTICES IN:

DO ANY OF THESE APPLY TO YOU?

 

LANGUAGE?

OTHER (specify) ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 3

 

 

 

 

RECIPIENT INFORMATION

 

 

PLEASE PRINT CLEARLY

Pregnant

1

 

FIRST NAME

 

 

 

M.I.

LAST NAME

 

 

 

 

 

 

 

MARITAL

 

PHONE NUMBER

Victim of Domestic Violence

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AREA CODE

 

Need to Establish Parentage

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

APT. NO.

CITY

 

COUNTY

 

STATE

ZIP CODE

Need Child Support

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug/Alcohol Problem

5

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fuel or Utility Shutoff

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Place to Stay/Homeless

 

 

MAILING ADDRESS (IF DIFFERENT FROM ABOVE)

 

 

 

 

APT. NO.

CITY

 

COUNTY

 

STATE

ZIP CODE

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire or Other Disaster

8

 

HOW LONG

YEARS

MONTHS

IS THIS A SHELTER?

ANOTHER PHONE

NAME

 

 

 

 

PHONE NUMBER

Have No Income

 

 

HAVE YOU LIVED

 

 

 

YES

NO

WHERE YOU

 

 

 

(

)

 

 

9

 

AT YOUR

 

 

 

 

CAN BE

 

 

 

 

 

 

AREA CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESENT ADDRESS?

 

 

 

 

 

 

REACHED

 

 

 

 

 

 

 

 

 

 

 

Serious Medical Problem

10

 

DIRECTIONS TO CURRENT ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pending Eviction

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Food

12

 

FORMER ADDRESS

 

 

 

 

 

 

 

 

APT. NO.

CITY

 

COUNTY

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Need Foster Care

13

 

IF YOU ARE CURRENTLY WITHOUT A HOME, CHECK HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Need Child Care

14

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Problems with English

15

 

AGENCY HELPING APPLICANT/CONTACT PERSON

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

Reasonable Accommodations

16

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AREA CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

17

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

YES NO

 

 

 

 

 

 

 

 

 

LIST THE THINGS THAT HAVE CHANGED SINCE YOUR APPLICATION OR LAST RECERTIFICATION (such as moved, had a baby, income, etc.) _______________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

CONSIDER
RCA/RMA REFERRAL
SELF
Social Security Number
of Recertifying Household Members
Does This Person (Including Minor Children) Buy Food or Prepare Meals with You?
Highest School
Grade Completed

LDSS-3174 Statewide (Rev. 07/20)

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This person is recertifying for:

Date of Birth:

Sex:

Gender Identity (Optional):

 

 

 

 

 

RI

LN

First Name, Middle Initial, Last Name

(Male, Female, Non-Binary, X,

 

Relationship

 

 

 

 

 

 

PA

SNAP

MA

(mm/dd/yyyy)

(M/F)

Transgender, Different Identity

 

to you:

(See instruction book, PUB-1313 Statewide,

 

 

 

 

 

[please describe])

 

 

 

 

 

 

 

 

or talk to your social services district)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

01

02

03

04

05

06

07

08

Line No.

ONC

FIRST NAME

 

M.I.

LAST NAME

 

 

PLEASE LIST MAIDEN OR

 

 

 

 

 

 

 

 

OTHER NAMES BY WHICH

 

 

 

 

 

 

 

 

YOU OR ANYONE IN YOUR Line No.

ONC

FIRST NAME

 

M.I.

LAST NAME

 

 

HOUSEHOLD HAVE BEEN

 

 

 

 

 

 

 

 

KNOWN

 

 

 

 

 

 

 

 

SECTION 7

 

 

 

 

 

 

 

 

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?

 

 

 

IF YES, INCIDATE BELOW.

 

 

 

YORK STATE BEFORE NOW?

YES

NO

IF YES, INCIDATE BELOW.

NAME

NAME

WHEN?

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

NAME

 

WHEN?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS ANYONE

YES

NO

IF YES, WHO

 

 

 

REASON

 

 

END DATE

 

 

 

 

 

 

 

 

 

 

SANCTIONED?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-APPLICANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEGALLY

 

 

 

 

 

 

 

 

 

 

 

RESPONSIBLE

 

FOR

CONTRIBUTION/

CHECK IF MEMBER

 

LN

 

FIRST NAME

 

LAST NAME

YES

 

NO

 

WHOM?

DEEMED INCOME

OF SNAP HOUSEHOLD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-CITIZEN WITH SATISFACTORY IMMIGRATION STATUS INFORMATION

 

 

 

 

 

 

 

INDIVIDUAL EDUCATION

NON-CITIZEN STATUS

STATUS

DATE OF

 

APPLIED FOR

SPONSORED

LN

DEGREE RECEIVED

LN

DEGREE RECEIVED

ADJUSTED

ENTRY/STATUS

CITIZENSHIP

 

 

 

 

LN

YES

NO

MONTH

DAY

YEAR

YES

NO

YES

NO

01

 

05

 

 

 

 

 

 

 

 

 

 

 

 

 

02 06

03 07

 

04

08

 

 

 

PAGE 2

YES NO

PAGE 3

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

LDSS-3174 Statewide (Rev. 07/20)

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

 

I

A

B

P

W

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANTICIPATED FUTURE ACTION

CASE TYPE

RELATED CASE NUMBERS

CONSIDER

 

 

 

LINE NO.

CODE

DATE

 

 

Relationship

REQUESTED

DOCUMENTATION

IN FILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Filing Unit

 

Photo ID

 

 

 

 

 

 

Legally Responsible Relative

 

Birth Verification

 

 

 

 

 

 

Single Economic Unit

 

Marriage License

 

 

 

 

 

 

SNAP Household Composition

 

Social Security Card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SNAP Aged/Disabled Individual

 

Code 9 Resolution

 

 

 

 

 

 

 

 

 

 

NEEDED

 

REFERRALS

COMPLETED

Photo ID

 

 

 

 

 

 

 

Immigration Status

 

AFIS (PA Only)

 

Legal

 

CBIC/PIN

Multi-Suffix/Co-op Case Notice (Single

 

Services

 

Economic Unit Questionnaire)

 

 

 

 

 

RFI/OCA

 

 

SSA

 

 

 

 

Health Insurance

 

 

NYSoH

 

 

 

 

Child Support Pass-Through

 

 

Chronic Care/SSI-Related

 

 

 

 

 

 

 

MA-Only

 

 

 

 

Medicare Savings Program

 

 

 

 

 

 

 

 

LDSS-3174 Statewide (Rev. 07/20)

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 (PUB-1313 Statewide) or talk to your social services district.

 

SECTION 9 – CITIZENSHIP/NON-CITIZEN WITH SATISFACTORY IMMIGRATION STATUS

 

 

 

SECTION 10 – CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

LIST EVERYONE WHO IS RECERTIFYING OR WHO IS REQUIRED TO RECERTIFY.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Supplemental Nutrition Assistance Program, or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid (except if the applicant is pregnant)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEEDED

 

REFERRALS

 

 

COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Systematic Alien Verification for Entitlements (SAVE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

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 non-citizen with a satisfactory immigration

 

 

 

 

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

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

 

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

satisfactory immigration status. (See the instruction book, Pub-1313

 

 

 

 

Statewide.)

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check either "CITIZEN / NATIONAL" or

USCIS NUMBER (ALIEN REGISTRATION

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

DATE

 

PA

 

N

 

MA

 

 

LN

FIRST NAME

MI

LAST NAME

 

"NON-CITIZEN"

 

NUMBER) OR NON-CITIZEN NUMBER

 

 

 

 

 

 

 

 

 

CERTIFICATION

 

 

 

 

A

 

 

 

 

 

 

 

 

for each person.

 

 

(If Applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

01

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

02

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

03

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

04

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

05

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

06

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

07

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

08

 

 

 

CITIZEN/

A

Sign Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NATIONAL

NON-CITIZEN

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By checking a box above and by signing the certification 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 non-citizen with satisfactory immigration status.

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 non-citizen status, if applicable.

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

LDSS-3174 Statewide (Rev. 07/20)

SECTION 11 – INFORMATION REGARDING REFERRAL TO THE CHILD SUPPORT ENFORCEMENT UNIT

 

If you are recertifying for Medicaid in addition to Public Assistance or the Supplemental Nutrition Assistance Program, you may have to help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTED

 

 

DOCUMENTATION

IN FILE

 

 

 

us obtain medical support for yourself and your recertifying children. Answer the following questions to determine if you need to complete this

 

 

 

 

 

 

 

 

 

Acknowledgment of Parentage

 

 

 

 

section. Include yourself, as appropriate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Paternity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support Order

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

Good Cause Form (LDSS-4279)

 

 

 

 

 

 

 

 

 

 

 

 

 

IV-D Attestation (LDSS-4281)

 

 

 

 

 

established? Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Death Certificate

 

 

 

 

 

2.

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorce Decree

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

VA Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Order of

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

Filiation/Paternity/Parentage

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Certificate

 

 

 

 

 

 

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

 

 

 

 

NEEDED

 

 

REFERRALS

 

COMPLETED

 

 

 

parents.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CTHP

 

 

 

 

 

3.

Are you under the age of 21? Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referral for Child Support

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Services (LDSS-5145)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parentage/Paternity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

CONSIDER

 

 

 

 

 

 

 

 

 

Health Insurance of Non-

 

 

 

 

 

 

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

 

 

 

 

 

Child Health Plus

 

 

 

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

 

 

 

 

 

 

 

custodial Parent/Absent

 

TASA

 

 

 

 

 

 

 

 

 

 

 

Spouse

 

 

 

 

 

cause, as a condition of obtaining assistance, you are required to cooperate with the Child Support Enforcement Unit to locate any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

Petition to Family Court

 

SSI/SSA

 

 

 

 

modify, and/or enforce orders of support. You also will be provided with the LDSS-4279 form, “Notice of Responsibilities and Rights for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NONCUSTODIAL PARENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF INDIVIDUAL UNDER AGE 21

 

NONCUSTODIAL PARENT OR ALLEGED PARENT’S NAME AND ADDRESS

 

OR ALLEGED PARENT’S

NONCUSTODIAL PARENT OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

ALLEGED PARENT’S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

DAY

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LDSS-3174 Statewide (Rev. 07/20)

 

 

 

 

 

 

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

PAGE 6

SECTION 12 – TAX FILING/DEPENDENT STATUS - Please select the tax status for each individual living in the household.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TAX STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

MIDDLE

 

LAST NAME

SINGLE

MARRIED

MARRIED

HEAD OF

 

QUALFIYING

 

DEPENDENT

 

WILL NOT BE

 

 

 

INITIAL

 

 

 

 

 

 

FILING

FILING

HOUSEHOLD

 

WIDOW(ER)

 

AND WILL BE

 

FILING TAXES

 

 

 

 

 

 

 

 

 

 

 

JOINTLY

SINGLE

(WITH

 

WITH

 

FILING TAXES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUALIFYING

 

DEPENDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDIVIDUAL)

 

CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

can skip this question.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF TAX DEPENDENT

 

 

 

 

 

 

 

 

 

NAME OF TAX FILER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

MIDDLE INITIAL

 

LAST NAME

 

 

 

 

FIRST NAME

 

MIDDLE INITIAL

 

 

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 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.

 

 

 

ADDRESS OF CHILD (STREET, CITY,

LEGAL PARENTAGE ESTABLISHED?

DO YOU PAY CHILD SUPPORT?

 

 

 

NAME OF PERSON

NAME OF ABSENT CHILD

DATE OF BIRTH

COUNTY, STATE, AND ZIP CODE)

 

 

 

 

 

 

 

 

 

 

 

RECERTIFYING

 

 

 

 

 

 

Yes

 

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 15 – TEEN PARENT INFORMATION

 

 

TEEN PARENT

 

 

 

 

 

 

 

 

 

TEEN PARENT CHILDREN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

 

LN NO.

 

 

 

Marital Status

 

 

 

 

LN NO.

__________________

 

High School Diploma/High School Equivalent?

 

 

 

 

 

 

Name ________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LN NO. _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LN NO.

 

 

 

Marital Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High School Diploma/High School Equivalent?

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of teen parent’s child _______________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAGE 7

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

LDSS-3174 Statewide (Rev. 07/20)

SECTION 16 – INCOME INFORMATION:

 

 

 

 

 

 

 

 

 

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

YES

NO

WHO

AMOUNT/VALUE &

WHO

AMOUNT/VALUE &

 

INCOME

 

 

 

 

 

FREQUENCY

 

FREQUENCY

 

 

 

Unemployment Insurance Benefits

 

 

 

 

 

LN

SOURCE

 

 

1

 

 

 

 

 

No.

CODE

AMOUNT

PERIOD

Supplemental Security Income (SSI) Benefits (State and Federal

 

 

 

 

 

 

 

 

 

Total)

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

Social Security Disability (SSD) Benefits

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

Social Security Dependent Benefits

4

 

 

 

 

 

 

 

 

Social Security Survivor’s Benefits

5

 

 

 

 

 

 

 

 

Social Security Retirement Benefits

6

 

 

 

 

 

 

 

 

Railroad Retirement Benefits

7

 

 

 

 

 

 

 

 

Retirement Benefits (Pensions)

8

 

 

 

 

 

 

 

 

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

9

 

 

 

 

 

 

 

 

Workers’ Compensation

10

 

 

 

 

 

 

 

 

NYS Disability Benefits

11

 

 

 

 

 

 

 

 

Veteran’s Pension/Benefits/Aid and Attendance

12

 

 

 

 

 

 

 

 

Public Assistance Grant

13

 

 

 

 

 

 

 

 

GI Dependency Allotments

14

 

 

 

 

 

 

 

 

Education Grants or Loans

15

 

 

 

 

 

 

 

 

Contributions/Gifts (Received)

16

 

 

 

 

 

 

 

 

Foster Care Payments (Received)

17

 

 

 

 

 

 

 

 

Child Support Payments (Received)

 

 

 

 

 

 

 

CONSIDER

 

Received From:________________________________________

 

 

 

 

Child Support Disregard/Pass-Through

 

 

18

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spousal Support (Received)

19

 

 

 

 

 

 

 

 

Explained Budgeted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SNAP Aged/Disabled Indicator

 

Private Disability Insurance - Health/Accident Insurance Policy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Review

 

Income

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reception

and Placement Grant (SNAP Only)

 

No-Fault Insurance Benefits

21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Union Benefits (including Strike Benefits)

22

 

 

 

 

 

 

Refugee Matching Grant

 

 

 

 

 

 

 

 

 

Change in Income from Last Budget

 

Loans, Other than Education (Received)

23

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

distributed)

24

 

 

 

 

 

 

 

 

 

 

 

Training Allotments/Stipends

25

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rental Income (Received)

26

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Boarders/Lodgers Income (Received)

27

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

Income

(Please

Specify)

LDSS-3174 Statewide (Rev. 07/20)

 

 

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

Deductions: Certain types of Medicaid budgeting allow

 

 

 

 

 

 

 

applicants/recipients to reduce their countable income with deductions

 

 

 

 

 

 

that they take on their federal taxes. These are specific expenses that

 

 

 

AMOUNT/VALUE &

 

AMOUNT/VALUE &

the Internal Revenue Service (IRS) allows people to deduct to reduce

YES

NO

WHO

WHO

FREQUENCY

FREQUENCY

 

 

 

 

their taxable income. Only record deductions here if you will claim them

 

 

 

 

 

 

on the current year’s tax return.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Educator expenses

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Retirement Account (IRA) deduction

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student loan interest deduction

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tuition and fees

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certain business expenses (reservists, artists, fee-based government

 

 

 

 

 

 

officials)

5

 

 

 

 

 

 

Health savings account deduction

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Job-related moving expenses

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S/E, SIMPLE & qualified plans

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S/E health insurance deduction

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Penalty on early withdrawal of savings

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alimony paid

12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic production activities deduction

13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

14

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Archer MSA deduction

15

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Adjustment

 

 

 

 

 

 

 

 

(Please Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAGE 8

SECTION 17 – STEPPARENT/NON-CITIZEN WITH SATISFACTORY

IMMIGRATION STATUS SPONSOR INFORMATION

Answer all questions listed below.

YES

NO

 

WHO?

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

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

NAME OF SPONSOR:

PHONE NO.:

NEEDED

 

REFERRAL

UIB

COMPLETED

ADDRESS:

PAGE 9

 

 

 

 

 

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

LDSS-3174 Statewide (Rev. 07/20)

 

SECTION 18 – EMPLOYMENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am currently:

employed

self-employed

unemployed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Income $ ________________

Hours Worked Monthly _________________

 

 

 

 

REQUESTED

 

DOCUMENTATION

 

IN FILE

 

 

 

(Include wages, salary, overtime pay,

 

 

 

 

 

 

 

 

 

 

 

CINTRAK/RFI/IRCS

 

 

 

 

 

 

 

 

commissions, and tips)

 

 

 

 

 

 

 

 

 

 

 

 

1099

 

 

 

 

 

 

 

 

 

Paid: Weekly

Biweekly

Monthly

Day of the week paid:

 

 

 

 

 

 

 

 

 

Employment Verification

 

 

 

 

 

 

Employer’s Name and Address:

 

 

 

 

 

 

 

1

 

 

 

 

Income Tax Return

 

 

 

 

 

 

 

 

______________________________________________

 

 

Phone No. __________________

 

 

 

 

 

Self-Employment Worksheet

 

 

 

 

 

______________________________________________

 

 

 

 

 

 

 

 

 

 

Wage Stubs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is anyone else who lives with you currently:

employed

self-employed

 

 

 

 

 

 

 

Work Registration Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent/Child Care Form/Statement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who: _________________________________________________

 

 

 

 

 

 

 

 

 

 

Approval of Informal Child Care Provider

 

 

 

 

 

Gross Income $ ________________

Hours Worked Monthly _________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paid: Weekly

Biweekly

Monthly

Day of the week paid:

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s Name and Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______________________________________________

 

 

Phone No. __________________

 

 

NEEDED

 

REFERRALS

 

COMPLETED

 

 

 

CONSIDER

 

 

 

 

 

 

 

 

 

 

 

 

Limited English Proficiency

 

 

______________________________________________

 

 

 

 

 

 

 

 

CAP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earned Income Tax Credit (see PUB-4786)

 

 

 

 

 

 

 

 

 

 

Disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explaining Periodic Reporting Requirements

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment

 

 

 

Net Loss of Cash Income

 

 

Is health insurance available through your employer?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

TPHI/COBRA

 

 

 

P.A.S.S. Income Amount and Sources

 

 

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

Yes

No

 

 

 

 

 

 

 

 

 

 

 

UIB

 

 

 

Employment Sanctions

 

 

Who: _________________________________________

 

 

 

 

 

3

 

 

 

 

 

Temporary Employment

 

 

 

 

 

 

 

 

 

Workers’ Compensation

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Review

 

 

Name of Insurance Company: _________________________________________________________

 

 

 

 

 

 

 

 

 

 

Drug/Alcohol

 

 

 

Individual Development Account (IDA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Violence

 

 

 

Voluntary Quit

 

 

 

 

 

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

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refugee Cash Assistance

 

 

 

 

 

 

 

 

 

expenses due to employment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who: _________________________________________

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

expenses?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who: _________________________________________

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LDSS-3174 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

PAGE 10

 

 

 

 

 

 

If not employed, when was the last time you or anyone who lives with you worked?

 

 

Who: _________________________________________

When: __________________________

 

Where: __________________________________________________________________________

6

Why did you (or they) stop working? ___________________________________________________

 

Did you or anyone living with you file for unemployment?

Yes

No

 

 

If yes, who? _______________________

When?: ________________

 

 

Status of filing: Approved Denied Pending

 

 

 

 

 

 

 

 

Are you or is anyone who lives with you participating in a strike?

Yes

No

 

Who: _________________________________________

 

 

 

7

 

 

 

 

When the strike began: ___________________________

 

 

 

 

 

 

 

 

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

Yes

No

 

worker?

 

 

 

 

 

 

 

 

Who: _________________________________________

 

 

 

8

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

Who: ____________________________________

Describe Limitations: _____________________________________________________________

_____________________________________________________________

 

 

 

9

 

 

 

 

Could you accept a job today?

Yes

No

10

 

 

 

If not, why? ________________________________________________________________________

 

 

 

 

What type of work would you like to do? _________________________________________

 

 

_________________________________________________________________________________

11

CHILD/DEPENDENT CARE EXPENSES

 

Who Pays

Amount

Name

Age

Care Provider

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAGE 11

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

LDSS-3174 Statewide (Rev. 07/20)

SECTION 19 – EDUCATION/TRAINING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What is your highest level of education completed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ Less than high school diploma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTED

 

DOCUMENTATION

 

 

 

IN FILE

 

 

 

 

 

 

If so, last grade completed? ______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Attendance

Verification

 

 

 

 

 

 

 

 

 

 

__ Completion of an Individualized Education Plan (IEP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(LDSS-3708)

 

 

 

 

 

 

 

 

 

 

 

__ High school diploma or General Equivalency Diploma (GED) or Test Assessing Secondary Completion (TASC™)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Educational Grant

Worksheet

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Care Statement

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone else in the household have a high school diploma, General Equivalency

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diploma (GED) or Test Assessing Secondary Completion (TASC™), or higher level of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

education?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, who: _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Degree attained:_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEEDED

REFERRALS

COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

Supportive Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date completed: _________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is or has been in any training program in the last 12 months?

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSIDER

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

Where

 

 

 

 

 

 

 

 

3

 

 

 

 

meet the SNAP student eligibility requirement?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

 

 

training?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates attended ________________________________

 

 

 

 

 

 

 

 

 

 

 

equivalency diploma and who is not attending school?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is anyone in training?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates completed _______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are any other supportive services appropriate?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

Yes

No

 

 

 

 

Are there any training related expenses?

 

 

 

 

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Where

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is getting a Training Allowance? Yes

No

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who _________________________________________

Amt. $

___

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is getting Educational Grants or Loans?

Yes

No

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who ________________________________________

Amt. $ _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is under 16 years of age and is attending school?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

 

 

 

 

 

 

 

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who

 

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LDSS-3174 Statewide (Rev. 07/20)

 

 

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

 

 

PAGE 12

SECTION 20 – RESOURCES INFORMATION

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT/VALUE

 

 

 

 

Has cash available

1

 

 

$

 

$

 

 

Legal

 

Has a checking account(s)

2

 

 

 

 

 

 

 

Resource

 

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

3

 

 

 

 

 

 

 

 

 

Has a credit union account(s)

4

 

 

 

 

 

 

 

 

 

Has life insurance

5

 

 

 

 

 

 

 

 

 

Has title or registration to a motor vehicle(s)

 

 

 

 

 

 

 

LIFE INSURANCE

 

or other vehicle(s):

 

 

 

 

 

 

FACE AMOUNT

CASH VALUE

Year ________ Make/Model ____________________________

 

 

 

 

 

 

 

 

 

Year ________ Make/Model ____________________________

 

 

 

 

 

 

 

 

 

Other______________________________________________ 6

 

 

 

 

 

 

 

 

 

Has stocks, bonds, certificates or mutual funds

7

 

 

 

 

 

 

 

 

 

Has savings bonds

8

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

 

Has an irrevocable burial trust

10

 

 

 

 

 

 

 

 

 

Has a burial fund

11

 

 

 

 

 

REQUESTED

DOCUMENTATION

IN FILE

Has a burial space

12

 

 

 

 

 

 

 

Resource Checklist

 

 

 

 

Has their own home

13

 

 

 

 

 

 

 

Market Value

 

 

 

 

 

Has real estate, including income-producing and

 

 

 

 

 

 

 

 

DMV Clearance

 

 

 

 

non-income-producing property

14

 

 

 

 

 

 

 

Bank Statement

 

 

 

 

Is eligible for an income tax refund

15

 

 

 

 

 

 

 

Assignment

 

of Proceeds

 

 

 

 

Has an annuity

16

 

 

 

 

 

 

 

Car/Vehicle

 

Title

 

 

 

 

Is the beneficiary of a trust

17

 

 

 

 

 

 

 

Car/Vehicle

 

Registration

 

 

 

 

 

 

 

 

 

 

 

(Older Models)

 

 

 

 

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

 

 

 

Bank Clearance

 

 

 

 

income from any other sources

18

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has an “in trust” account(s)

19

 

 

 

 

 

 

 

RFI/OCA

 

 

 

 

 

 

 

 

 

 

 

 

 

1099

 

 

 

 

 

 

Has a safe deposit box(es)

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has resources other than those listed above

21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has anyone (including your spouse, even if not recertifying or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

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

22

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSIDER

 

 

 

Has anyone (including your spouse, even if not recertifying or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Children’s Resources

 

 

 

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

 

 

 

Lump Sum

 

 

 

assets to a trust within the past 60 months?

 

 

 

 

 

 

 

 

 

 

 

 

 

Boats, Campers, Snowmobiles

 

 

 

If yes, when? _______________________________________23

 

 

 

Individual Development Account (IDA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE INFORMATION

 

 

 

 

 

Exempt Vehicles

 

 

 

 

 

 

EXEMPT

 

 

YR.

MAKE

MODEL

OWNER’S NAME

AMOUNT OWED

NADA VALUE

LIEN HOLDER

ACCOUNT NO.

EIC

YES*

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

Change in Resources from Last Budget

$

$

*IF EXEMPT, WHY?

PAGE 13

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

LDSS-3174 Statewide (Rev. 07/20)

SECTION 21 – MEDICAL INFORMATION

 

 

 

 

 

 

 

REQUESTED

DOCUMENTATION

IN FILE

 

 

 

 

 

 

 

 

 

Pregnancy Statement

 

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

 

 

 

 

 

 

 

 

 

 

 

YES

NO

IF YES, WHO

 

 

 

 

 

Med/Psych Statement

 

Has any medical bills or medically-related expenses

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug/Alcohol Screening (LDSS-4571)

 

Is on Medicaid with a spend-down

2

 

 

 

 

 

 

 

 

Drug/Alcohol Statement

 

 

 

 

 

 

 

 

 

 

 

Paid or Unpaid Medical Bills

 

 

 

 

 

 

POLICY NO.:

 

 

 

 

 

Has health or hospital/accident insurance (including insurance

 

 

 

 

AMOUNT:

 

 

 

 

SSI Application Verification (PA ONLY)

 

from employer)

3

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY OF PAYMENT:

 

 

 

 

CONSIDER

 

 

 

 

 

 

 

 

AD/SSI Related

 

Has health insurance available through an employer

4

 

 

 

INSURANCE COMPANY NAME:

 

 

 

 

 

 

 

 

SNAP Aged/Disabled Indicator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHO IS COVERED:

 

 

SNAP Medical Deduction

 

Has Medicare (red, white, and blue card)

5

 

 

 

 

 

 

 

 

 

 

 

TPHI Reimbursement

 

 

 

 

 

 

 

 

 

 

 

 

 

EFFECTIVE DATE:

 

 

Buy-In Eligibility

 

Has a health attendant/home health aide

6

 

 

 

 

 

 

 

 

 

 

 

Kreiger (LDSS-3664)

 

 

 

 

 

 

 

 

 

 

 

Domestic Violence

 

Is blind, sick or disabled

7

Is the answer to question 7 in this section consistent

SSI Referral

 

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 (D-CAP)

 

Has paid or unpaid medical bills within 3 months preceding

 

 

 

 

Disability Interview (LDSS-1151)

 

the month of this recertification

10

 

 

 

Medical Report (LDSS-486, 486t)

 

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

 

 

 

 

ACCES-VR

 

Is pregnant

 

 

 

 

 

 

 

 

 

CTHP

 

If pregnant, due date: _____________________________

14

 

 

 

 

 

 

 

Family Planning

 

Expected number of births: _________________________

 

 

 

 

 

 

 

 

 

 

 

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 work-related accident in the past two

 

 

Home Care

 

 

years

18

 

 

 

NYSoH

 

 

Has had a government agency (public program) besides Medicaid

 

 

MA-Only (DOH-4220)

 

 

or Medicare pay any of your medical bills

 

 

 

 

SSI-Related/Chronic Care

 

 

If yes, what agency _____________________

19

 

 

 

(DOH-4220 with Supplement A)

 

 

 

 

 

 

 

LDSS-4526 or local equivalent

 

 

Will billing any other health insurance cause harm to your physical

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

and confidentiality of your application for or receipt of Medicaid?

 

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LDSS-3174 Statewide (Rev. 07/20)

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 1-800-505-5678.

 

 

 

 

 

 

 

Primary Care Provider (PCP) or

 

Name of Plan You Are Enrolling In

Last Name

First Name

Date Of Birth

Sex

ID# (from Medicaid Card

Social Security #

Health

Name and ID# of OB/GYN

mm/dd/yy

M/F

if you have one)

(optional if pregnant)

Center (check box if current

(check box if current provider)

 

 

 

 

 

 

 

 

 

 

provider)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 22 – SHELTER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHAT IS YOUR LANDLORD’S NAME?

 

 

 

 

SHELTER

MONTHLY

 

 

 

 

 

 

 

 

COSTS

ACTUAL COST

 

______________________________________________________________________

 

 

A. Room and Board

 

 

 

 

 

B. Rent

 

 

 

 

 

 

 

 

 

 

 

WHAT IS YOUR LANDLORD’S ADDRESS?

 

 

 

 

 

 

C. Trailer Lot Rent

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________________________________

 

 

D. Mortgage Payment

 

 

 

 

 

 

 

 

 

1.

Principal

 

 

 

_______________________________________________________________________

 

 

 

2.

Interest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Property Tax

 

 

 

_______________________________________________________________________

 

 

 

 

(including

 

 

 

 

 

 

 

 

 

 

School Tax)

 

 

 

WHAT IS YOUR LANDLORD’S PHONE NUMBER?

 

 

 

 

 

 

 

 

 

 

4.

Homeowner’s

 

 

 

 

 

 

 

 

 

 

 

 

( ) _________________________________________________________

 

 

 

Insurance

 

 

 

 

 

 

(incl. Fire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

IF YES,

 

 

 

Insurance)

 

 

 

 

AMOUNT

 

 

5.

Taxes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Included

 

 

 

Do you or anyone who lives with you have a rent, mortgage or

 

 

$

 

 

 

in Mortgage

 

 

 

 

 

 

 

 

(Escrow

 

 

 

other shelter expense?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Payment)

 

 

 

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

 

 

$

 

 

6.

Assessments

 

 

 

 

 

 

 

 

(Sewer, etc.)

 

 

 

from your rent or other shelter expense?

 

 

 

 

E. Total Mortgage

 

 

 

 

 

 

 

 

 

Payment (Line 1-6)

 

 

 

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

(Lines A - E)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUESTED

DOCUMENTATION

IN FILE

Landlord Statement

Rent Receipt

Tenant of Record

Customer of Record

Voluntary Restrict

Mandatory Restrict

Subsidized Housing

Mortgage/Title Search

Section 8 Lease or Statement from

Section 8 Office

Property Lien

Shelter/Utility Repayment Agreement

CONSIDER

Utility and/or Fuel Restrict

Utility Guarantee

HEAP

Subsidized Housing May Show Total Rent, NOT Client Amount

Foster Care-Related Additional Allowances

SNAP Household Composition Rules

SNAP Aged/Disabled Indicator

Real Property Tax Credit

AIDS/HIV Emergency Shelter Allowance

Property Lien

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

PAGE 15

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

LDSS-3174 Statewide (Rev. 07/20)

SECTION 22 – SHELTER (CONT.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you or anyone who lives with you have the following

 

 

YES

NO

 

IF YES,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

expenses separate from your rent or other shelter expense?

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

hot water, etc.)

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

water, etc.)

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN WHOSE NAME IS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE BILL?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTHLY

 

 

 

MONTHLY

NAME OF

ACCOUNT

(CUSTOMER OF

WHO IS THE TENANT

 

Water

3

 

 

$

 

 

 

EXPENSES

 

 

ACTUAL COST

DEALER

NUMBER

RECORD)

OF RECORD?

 

 

 

 

 

A. Heat*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

Air Conditioning

4

 

 

$

 

 

C. Gas (for cooking, hot water)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Propane (for needs other than heat)

5

 

 

$

 

 

D. Liquid Propane Gas

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Other Utilities or Expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sewer

6

 

 

$

 

 

F. Air Conditioning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G. Utility Installation Fees

 

 

 

 

 

 

 

 

 

Trash

7

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H. Sewer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

I. Trash

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Utilities and Expenses

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J. Water

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you live in public housing?

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Check Primary Heat Type:

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you live in a drug/alcohol treatment facility?

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Natural Gas

Oil

 

 

 

 

PSC Electric

Coal

Other ________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kerosene

Propane

 

 

Municipal Electric

Wood

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 23 – OTHER EXPENSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indicate if you or anyone who lives with you who is

 

YES

NO

 

 

IF YES, AMOUNT

HOW

 

LEGALLY

CHILD IN

 

 

 

 

 

 

 

 

 

OFTEN

 

OBLIGATED

SNAP HH

 

 

 

 

 

 

recertifying:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays child support

1

 

 

 

 

$

 

 

 

 

 

YES

 

NO

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays spousal support

2

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays for child care

3

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays for dependent care

4

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pays tuition, fees, or other educational expenses

5

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has additional expenses (Example: car payment, car

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

insurance payment, credit card payments, other loan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

payments, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify: _______________________________

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you or anyone who lives with you who is recertifying

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

age of 21?

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LDSS-3174 Statewide (Rev. 07/20)

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM

PAGE 16

SECTION 24 – OTHER INFORMATION

 

 

 

 

 

 

Do you buy or plan to buy meals from a home

YES

NO

 

 

 

 

delivery or communal dining service?

8

 

 

 

 

 

 

 

 

 

 

 

 

Are you able to cook or prepare meals at home?

9

YES

NO

VETERAN

VETERAN

 

 

 

 

 

 

STATUS

CODE

NEEDED

REFERRALS

COMPLETED

CONSIDER

Have you or anyone in your household ever been in the U.S. military?

YES

NO

 

 

 

Services

SNAP Dependent Care Deductions

 

 

 

 

 

 

Who? ________________________________________

10

 

 

 

 

 

 

 

 

 

 

 

UIB

District of Fiscal Responsibility (SSL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

62.5)

 

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

11

YES

NO

 

 

 

 

 

 

Is anyone in your household a dependent of someone who is or was

YES

NO

 

 

REQUESTED

DOCUMENTATION

IN FILE

 

 

 

 

Child/Dependent Care

 

in the U.S. military?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Statement

 

Who? ________________________________________

12

 

 

 

 

 

 

 

 

 

 

 

 

 

Recoupments

 

 

 

 

 

 

 

 

 

 

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

YES

NO

WHO

 

 

 

 

 

 

 

Outstanding Overpayment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you or anyone who lives with you who is recertifying moved into

 

 

 

 

 

 

 

 

 

 

Pending Disqualification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

this county from another New York State county within the past two

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

months?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you or anyone who lives with you ever been found guilty of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and/or been disqualified for Public Assistance and/or the

 

 

 

 

 

IF TOTAL EXPENSES (INCLUDING EXPENSES NOT USED IN THE BUDGET DETERMINATION)

 

 

 

 

 

EXCEED INCOME (INCLUDING PA GRANT), EXPLORE HOW THE HOUSEHOLD IS MEETING ITS

Supplemental Nutrition Assistance Program (SNAP) because of

 

 

 

 

 

 

 

 

 

 

OBLIGATIONS.

 

 

 

 

 

 

 

 

fraud/an Intentional Program Violation?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSIDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you or anyone who lives with you received benefits for which

 

 

 

 

 

Actual Expenses

 

 

 

 

 

Actual Expenses, including: shelter,

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

fuel/utility costs, telephone costs, etc.

they were not entitled, which have not been fully repaid to this or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual Shelter

another agency?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual Fuel/Utility Costs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Expenses

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

Have you or any member of your household been convicted of making

 

 

 

 

 

Actual Income

 

 

 

 

Car Expenses

 

 

 

 

 

 

 

 

 

 

Furniture/Appliance Rental

a fraudulent statement or representation of residence in order to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

receive Public Assistance in two or more states?

 

 

 

 

 

 

 

 

 

 

 

 

Cable TV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

= Difference

 

$

 

 

 

Tuition

Have you or any member of your household been convicted of

 

 

 

 

 

 

 

 

 

Out-of-Pocket Medical Expenses

 

 

 

 

 

 

 

 

 

 

 

 

fraudulently receiving duplicate SNAP Benefits in any state after

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

September 22, 1996?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does Client Receive Contribution Towards Difference

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, From Whom? __________________________

 

Have you or any member of your household been convicted of buying

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or selling SNAP Benefits for a combined amount of over $500 or more

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

after September 22, 1996?

 

 

 

 

 

Based on the information contained in this recertification, make sure you reconsider the

 

 

 

 

 

 

Have you or any member of your household been convicted of trading

 

 

 

 

 

 

 

 

 

 

category. For PA, especially, consider the following:

 

 

SNAP benefits for firearms, ammunition or explosives, or drugs?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you or any member of your household fleeing to avoid

 

 

 

 

 

Eligible Child Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

prosecution, custody or confinement after conviction of a felony or

 

 

 

 

 

Essential Persons Status

 

 

 

 

 

 

 

Family Assistance Extensions

 

 

attempted felony and actively being pursued by law enforcement?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you or any member of your household violating probation or

 

 

 

 

 

Category is _____________________________________________

parole according to a court order?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY TRANSFER STATUS

 

 

 

 

 

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

LDSS-3174 Statewide (Rev. 07/20)

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 1-800-772-1213).

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 1320b-7) and Section 7(a)(2) of the Privacy Act of 1974. See the instruction book (PUB-1313 Statewide) or talk to your social services district if you have questions.

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

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

LDSS-3174 Statewide (Rev. 07/20)

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) 877-8339. Additionally, program information may be made available in languages other than English.

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

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

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

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

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

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

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

This institution is an equal opportunity provider.

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

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

If I am 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

LDSS-3174 Statewide (Rev. 07/20)

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, non-citizen with satisfactory immigration status/citizenship status, able-bodied adult without dependents (ABAWD) status, pregnancy status or living arrangements, to the best of my knowledge or belief.

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

PENALTIES – Federal and state laws provide for penalties of fine, imprisonment or both if you do not tell the truth when you 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 community-based waivered services for a period of time. It is unlawful to obtain Assistance, Benefits or Services by concealing information or providing false information.

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

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

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

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

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

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

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

12 months for the first SNAP IPV;

24 months for the second SNAP IPV;

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

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

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

LDSS-3174 Statewide (Rev. 07/20)

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 non-household member in order to get a SNAP deduction for these expenses. Failure to report/verify the above expenses will be seen as a statement by your household that you do not want to receive a deduction for these unreported/unverified expenses. A deduction for these expenses may make you eligible for SNAP or may increase your SNAP benefits. You may report/verify these expenses at any time in the future. The deduction would then be applied to the calculation of SNAP benefits in future months, in accordance with the rules for change reporting (see Change Reporting, above).

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 health-related information about me and any members of my family for whom I can legally give authorization related to the provision of assistance and services and my ability to participate in work activities, including employment, to the New York State Office of Temporary and Disability Assistance (OTDA), the New York State Office of Children and Family Services or the local social services district, as reasonably necessary for the provision of Public Assistance benefits; for services, including child welfare services; for determining appropriate work activity assignments; for determining the need to apply and for making application for Supplemental Security Income Benefits; for establishing appropriate treatment plans for restoring employability; and for determining eligibility for exemptions from the State sixty-month time limit on cash assistance receipt. If I am required to apply for benefits administered by the Social Security Administration, the information specified above may be shared with the Social Security Administration. I also agree that the information released may include HIV, mental health or alcohol and substance abuse information about me and members of my family, to the extent permitted by law, unless a box is checked below. If more than one adult in the family is joining a Medicaid health plan, the signature of each adult

PAGE 21

LDSS-3174 Statewide (Rev. 07/20)

applying is necessary for consent to release information. I understand that my ability to consent to the release of information relating to any minor children for whom I may give consent is limited by the extent to which I can obtain information regarding treatment, diagnosis and procedures on their behalf.

_______ Do not disclose HIV/AIDS information

______ Do not disclose drug and alcohol information

_______ Do not disclose mental health information

 

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

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

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

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

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

REIMBURSEMENT OF MEDICAL EXPENSES

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

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

LDSS-3174 Statewide (Rev. 07/20)

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 community-based services, and related hospital and prescription drug services received on or after my 55th birthday.

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

AUTHORIZATION TO REPAY PUBLIC ASSISTANCE BENEFITS FROM RETROACTIVE SUPPLEMENTAL SECURITY INCOME – I authorize the Commissioner of the Social Security Administration (SSA) to use my first payment of Supplemental Security Income (SSI); i.e. my retroactive SSI payment) to reimburse the local social services district (SSD) for Public Assistance (PA) the SSD pays me from State or local funds while SSA decides if I am eligible for SSI. SSA will not reimburse the SSD for PA that was paid using any federal funds.

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

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

SSA can reimburse the SSD in two situations:

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

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

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

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

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

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

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

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

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

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

PAGE 23

LDSS-3174 Statewide (Rev. 07/20)

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) 942-6906 and (800) 818-0656 (TTY).

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

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

APPLICANT SIGNATURE

DATE SIGNED

SPOUSE OR PROTECTIVE REPRESENTATIVE SIGNATURE

DATE SIGNED

x

 

x

 

 

 

 

 

AUTHORIZED REPRESENTATIVE

DATE SIGNED

 

 

SIGNATURE

 

 

 

x

 

 

 

ONLY COMPLETE THE FOLLOWING IF YOU WANT TO 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 _______________________________

 

 

 

NYS Agency-Based Voter Registration Form

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

 

 

 

 

Important!

 

 

 

 

 

 

 

like to apply to register here today?”

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

If you checked YES, please complete the

 

 

 

If you do not check

 

 

 

 

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

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

any box, you will

 

 

 

 

 

 

 

 

 

VOTER REGISTRATION APPLICATION below

 

 

 

 

 

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

 

 

 

 

 

 

be considered to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO because I choose not to register OR

 

 

 

have decided not

 

 

 

 

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

 

 

 

 

I am already registered at my current address OR

 

to register to vote

 

 

 

 

You may fill out the application form in private.

 

 

 

 

 

 

 

 

at this time.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

I asked for and received a mail registration form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LLAME AL 1-800-367-8683

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

中文資料:若您有興趣索取中文資料表格,請電: 1-800-367-8683

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

한국어: 한국어 한국어 양식을 원하시면 1-800-367-8683

 

 

 

Signature

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

으로 전화 하십시오.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

যিদ আপিন এই ফর্মিট বাংলা ভাষায় চান , তাহেল

 

Please Print Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1-800-367-8683 নমব্ের ফন করুন

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VOTER REGISTRATION APPLICATION (instructions on back)

 

 

 

 

 

Yes, I need an application for an Absentee Ballot

 

 

Please print or type in blue or black ink

Yes, I would like to be an Election Day worker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you a U.S. citizen?

 

 

 

 

 

 

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

YES

NO

 

For Board Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

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

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

2

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

If you answered NO, do not complete this form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

election?

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

First Name

 

 

 

 

 

 

Middle Initial

Suffix

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

Apt. No.

 

 

 

 

City/Town/Village

 

Zip Code

 

 

County

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

P.O. Box, Star Route, etc.

Post Office

 

Zip Code

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Gender (optional)

 

 

 

Telephone (optional)

 

 

 

 

 

Email (optional)

 

 

 

6

 

 

 

 

 

 

7

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The last year you voted

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

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

 

 

New York State DMV number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In county/state

Under the name (if different from your name now)

 

 

Last four digits of your Social Security number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Political Party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Affidavit: I swear or affirm that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• I am a citizen of the United States.

 

 

 

 

 

 

 

 

I wish to enroll in a political party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

Democratic party

 

 

Libertarian party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the election.

 

 

 

 

 

 

 

 

 

 

 

Republican party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Independence party

 

 

 

 

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

 

 

 

 

 

Conservative party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

 

 

SAM party

 

 

 

 

12

 

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

 

 

 

 

Working Families party

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

Green party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature or Mark in ink

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Optional) Register to donate your organs and tissues

Last Name

First Name

 

Middle Initial

 

Suffix

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt Number

City/Town/Village

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

Birth Date

Gender

 

 

 

 

 

 

M

 

F

 

 

 

 

 

 

 

 

 

Eye Color

Height

 

 

 

 

 

 

 

Ft.

In.

 

 

 

Email

DMV or ID NYC Number

 

 

 

 

 

 

 

 

 

By signing below, you certify that you are:

16 years of age or older

Consent to donate all of your organs and tissues for

transplantation, research, or both;

Authorizing the Board of Elections to provide your name and identifying information to NYS Donate Life Registry for enrollment;

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

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

/ /

Signature

Date

Qualifications for Registration

You Can Use This Form To:

register to vote in New York State;

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

enroll in a political party or change your enrollment;

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

To Register You Must:

be a U.S. citizen;

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

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

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

not claim the right to vote elsewhere; and

not found to be incompetent by a court.

Important!

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

NYS Board of Elections

40 North Pearl St, Suite 5

Albany, NY 12207-2729

Telephone: 1-800-469-6872;

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

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

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

Verifying your identity

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

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

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

To complete this form:

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

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

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

BOX 11: Check one box only. Political party enrollment is optional but that, in order to vote in a primary election of a political party, a voter must enroll in that political party, unless state party rules allow otherwise.

Rev. 2/05/2020