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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 By Fax Mailing Address otda*sm*ssp otda*ny. gov 518 486-3459 SSI State Supplement Program PO Box 1740 Albany New York 12201 II. Client Identification Name Social Security Number last four XXX-XXX- Date of Birth / New Residence Address New Provider Name and Address Former Provider Name and Address County Certificate/License/Provider III. Nature of Placement Transfer or Other Change Type of Placement Type of Care Federal/State Living Arrangement Move Into Moved Out of Federal Living Arrangement Code A State Code C Medical facility Community or Other please specify e*g* deceased Effective Date s of Change IV. Custody For children under 18 years old who has legal 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. Payee Signature Resident Signature Must be the Representative Payee approved by 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 Signature Title Date Telephone Have Questions or need More Information 1-855-488-0541 www. Return Instructions Please return this completed form to By E-mail By Fax Mailing Address otda*sm*ssp otda*ny. gov 518 486-3459 SSI State Supplement Program PO Box 1740 Albany New York 12201 II. Client Identification Name Social Security Number last four XXX-XXX- Date of Birth / New Residence Address New Provider Name and Address Former Provider Name and Address County Certificate/License/Provider III. gov 518 486-3459 SSI State Supplement Program PO Box 1740 Albany New York 12201 II. Client Identification Name Social Security Number last four XXX-XXX- Date of Birth / New Residence Address New Provider Name and Address Former Provider Name and Address County Certificate/License/Provider III. Nature of Placement Transfer or Other Change Type of Placement Type of Care Federal/State Living Arrangement Move Into Moved Out of Federal Living Arrangement Code A State Code C Medical facility Community or Other please specify e*g* deceased Effective Date s of Change IV. Nature of Placement Transfer or Other Change Type of Placement Type of Care Federal/State Living Arrangement Move Into Moved Out of Federal Living Arrangement Code A State Code C Medical facility Community or Other please specify e*g* deceased Effective Date s of Change IV. Custody For children under 18 years old who has legal Parent/Guardian Social Services Other specify V.

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