Ldss 5023 Form PDF Details

The LDSS-5023 form, issued by the New York State Office of Temporary & Disability Assistance, serves a crucial role in the administration of congregate care changes for individuals receiving assistance. This detailed document guides users through the process of reporting any shifts in living arrangements, whether it's moving into or out of various levels of congregate care, medical facilities, or other specified living situations. It meticulously collects client identification information, including name, social security number, and address changes. Additionally, it covers a broad range of reportable changes, from the nature of placement or transfer to adjustments in custody for minors, income fluctuations, and resource tallies. The form also facilitates the authorization for direct deposits of State Supplement Program (SSP) benefits, requiring detailed banking information and signatures from the payee or the resident themselves, depending on the context. With return instructions clear on submission via email, fax, or mail, and contact information for further assistance, the LDSS-5023 form embodies a comprehensive approach to ensuring that individuals in congregate care settings have their changes accurately reported and processed, reflecting the state’s commitment to the welfare of its residents.

QuestionAnswer
Form NameLdss 5023 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform, ny, social, representative

Form Preview Example

LDSS-5023 (Rev. 2/15)

NYS Office of Temporary & Disability Assistance

Congregate Care Change Report Form

I. Return Instructions

 

 

Please return this completed form to:

By E-mail:

otda.sm.ssp@otda.ny.gov

 

By Fax:

(518) 486-3459

Mailing Address:

SSI State Supplement Program

 

 

PO Box 1740

 

 

Albany, New York 12201

II. Client Identification

Name:

Social Security Number (last four):

Date of Birth:

 

XXX-XXX-

/

/

 

 

 

 

New Residence Address:

 

 

 

 

 

 

 

New Mailing Address (If Different than Residence Address):

 

 

 

 

 

 

New Provider Name and Address:

Former Provider Name and Address:

 

 

County:

County:

 

 

Certificate/License/Provider #

Certificate/License/Provider #

 

 

 

 

 

 

III. Nature of Placement, Transfer or Other Change

Type of

Type of Care(Federal/State Living Arrangement)

Effective Date(s) of Change

Placement

 

 

Move Into

Congregate Care Level 1 – Family Care

 

Moved Out of

Federal Living Arrangement Code A, State Code C

 

 

 

 

Move Into

Congregate Care Level 2 – Residential Care

 

Moved Out of

Federal Living Arrangement Code A, State Code D

 

 

 

 

Move Into

Congregate Care Level 3 – Enhanced Residential Care

 

Moved Out of

Federal Living Arrangement Code A, State Code E

 

 

 

 

Move Into

Medical facility

 

Moved Out of

Federal Living Arrangement Code A/D, State Code Z

 

 

 

 

Move Into

Community or Other (please specify, e.g. deceased):

 

Moved Out of

 

 

 

 

 

LDSS-5023 (Rev. 2/15)

NYS Office of Temporary & Disability Assistance

Congregate Care Change Report Form

IV. Custody

For children under 18 years old, who has legal Custody?

Parent/Guardian

Social Services

Other (specify)

_______________________________

V.Income Changes

Type of Income: (e.g. Social Security Retirement, Social Security Disability, Pension, Wages)

Amount:

Date Income Changed:

VI. Resources

Total countable Resources equal: $_______________________ effective_________________________

VII. Authorization for Direct Deposit

As the payee* for this resident, I am requesting

 

I am requesting that my SSP benefits be deposited into the

 

that his/her SSP benefits be deposited into the

 

bank account listed below.

 

bank account listed below.

 

 

 

______________________________________

 

 

 

(Payee Signature)

 

 

 

 

 

 

 

*Must be the Representative Payee approved by

 

(Resident Signature)

 

SSA or the Designated Representative (DR) Payee

 

 

 

approved by the SSP. To apply to become the DR

 

 

 

Payee please call 1-855-488-0541

 

 

 

Bank Name and Address_______________________________________________________________________

Name on Account: ___________________________________________________________________________

Routing Number_______________________________________________________________________________

Account Number _____________________________________________________________________________

Type of Account

Checking

Savings

VIII. Authorization

Name:

 

 

Title:

 

 

 

 

Signature:

Date:

 

Telephone:

 

 

 

 

 

 

 

E-mail:

 

Have Questions or need More Information?

 

 

1-855-488-0541

 

www.otda.ny.gov/programs/ssp

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