Get "request For Voluntary Restricted Payments" (form Ldss-4580) - Otda Ny

Filling out the "Request For Voluntary Restricted Payments" (Form LDSS-4580) is an important step for individuals seeking to have specific payments made directly from their Temporary Assistance Grant. This guide will provide clear, step-by-step instructions to assist users in completing the form online efficiently.

Follow the steps to successfully complete your request for restricted payments.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling out the case name at the top of the form. Ensure that the name matches the records held by the Department of Social Services.
3. Next, provide your address in the designated field, ensuring completeness and accuracy.
4. Indicate the category or case type by selecting the appropriate option from the provided list.
5. Enter your case number in the specified space. This information is crucial for processing your request.
6. For the shelter section, specify the amount you wish to restrict from your Temporary Assistance Grant and provide it in the space provided.
7. For energy-related restrictions, carefully read the options and select one that applies to your situation: Domestic Energy Only, Heating Only, or Combined Domestic Energy/Heating. Fill in the respective amounts as required.
8. If applicable, check the boxes for energy payments that request the Department of Social Services to pay your entire Domestic or Heating bill.
9. Add your signature in the signature field and include the date to validate your request.
10. If a worker or witness is involved, they should also sign and date the form in the designated fields.
11. After filling out the form, review it for accuracy and completeness before saving your changes, downloading, printing, or sharing the completed document.

Take the necessary steps to ensure your financial support by completing your document online today.