
LDSS4942 (Rev. 10/16)NYSOTDASUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) AUTHORIZED REPRESENTATIVE REQUEST FORMIf you are blind or seriously visually impaired and need this application/form in.
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How to fill out the NY LDSS-4942 online
Filling out the NY LDSS-4942 form online can seem daunting, but it is a straightforward process when approached step by step. This guide will provide you with clear instructions to ensure that you fill out the form accurately and efficiently.
Follow the steps to complete the NY LDSS-4942 form online.
- Click ‘Get Form’ button to obtain the LDSS-4942 form and open it in your preferred document viewer.
- Begin by entering your applicant or recipient name in the designated field. Make sure to provide your full legal name.
- Next, fill in your complete address. This should include your street number, street name, city, state, and zip code.
- Locate the applicant or recipient case number field and enter your case number as provided by your social services district. If you do not have a case number, leave this field blank.
- Proceed to the section labeled 'authorized representative'. If you wish to authorize someone to act on your behalf, provide their name, address, and phone number in the corresponding fields.
- In the 'I authorize the above designated individual' section, check the boxes depending on the authorization you wish to grant. You may choose to allow your representative to apply for SNAP benefits, use your SNAP benefits card, or recertify your benefits.
- Read the SNAP penalty warning carefully to understand the implications of providing incorrect information. Acknowledge this by signing and dating the applicant signature line.
- As the authorized representative, they must also sign and date their section, acknowledging the information provided.
- After completing all fields, you have the option to save changes, download the form for your records, print it, or share it as needed.
Complete your NY LDSS-4942 form online today to ensure you receive the benefits you may be eligible for.
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