Ldss 5023 Form PDF Details

Do you need to file an Ldss 5023 form for your business? Understanding the purpose of this document and knowing the necessary steps to complete it correctly can be overwhelming, especially if you're new to small business ownership. In this blog post, we'll discuss everything you need to know about filing an Ldss 5023 form―including important tips and insider information on how to make sure your application is accepted without a hitch. We'll also provide some helpful resources so that you can get started right away in submitting your form with confidence.

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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