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Get NY LDSS-3174 2020-2024

DO NOT WRITE IN THE SHADED AREAS OF THIS RECERTIFICATION FORM LDSS-3174 Statewide Rev. 5/05 CENTER/ OFFICE INTERVIEW DATE UNIT ID WORKER ID CASE TYPE CASE NUMBER DISTRICT CASE NAME LIFELINE EFFECTIVE DATE PAGE 1 CATEGORY ELIGIBILITY APPROVED BY SUPERVISOR NUMBER REUSE INDICATOR DISPOSITION RECERTIFICATION ELIGIBILITY DETERMINED BY WORKER LANG FORM 0F CLOSE REASON CODE SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION DATE X DATE RECEIVED BY AGENCY EMPLOYED BY SOCIAL SERVICES DISTRICT PROVIDER AGENCY TA AUTHORIZATION PERIOD SPECIFY FROM TO NEW YORK STATE We are committed to assisting and supporting you in a professional and respectful manner with your goal of achieving self-sufficiency. You in turn must be committed to becoming self-sufficient and must be responsible for participating in activities to reach self-sufficiency including work activities for Temporary Assistance and Food Stamp Benefits where required* Whenever you see Temporary Assistance or TA on the recertification form it means Family Assistance and Safety Net Assistance. We call both Public Assistance Programs Temporary Assistance. These TA Programs are meant to assist you only until you can fully support yourself and your family. Please refer to the How to Complete instruction book Pub-1313 Statewide when completing this recertification form* CHECK EACH PROGRAM YOU OR ANY HOUSEHOLD MEMBER WANTS TO RECERTIFY FOR Temporary Assistance and Medical Assistance Medicare Savings Program Food Stamp Benefits Medical Assistance DO ANY OF THESE APPLY TO YOU HOUSE NO. M. I. Urgent Personal Or Family Problem Fire Or Other Disaster Have No Job Serious Medical Problem Recently Lost Income Need Child Care Other OTHER specify PLEASE PRINT CLEARLY MARITAL STATUS LAST NAME STREET ADDRESS RECIPIENT INFORMATION FIRST NAME Need To Establish Paternity AREA CODE PHONE NUMBER SPANISH Need Foster Care ENGLISH Victim Of Domestic Violence No Food ENGLISH ONLY Pending Eviction SPANISH AND ENGLISH WHAT IS YOUR PRIMARY LANGUAGE Pregnant No Place To Stay/Homeless DO YOU WANT TO RECEIVE NOTICES IN APT. NO. CITY Need Child Support STATE ZIP CODE COUNTY Drug/Alcohol Problem Fuel Or Utility Shutoff CARE OF NAME Complete if you receive your mail in care of another person MAILING ADDRESS IF DIFFERENT FROM ABOVE AGENCY HELPING RECIPIENT/CONTACT PERSON HOW LONG HAVE YOU LIVED AT YOUR DIRECTIONS TO HOME YEARS MONTHS IS THIS A SHELTER FORMER ADDRESS YES NO ANOTHER PHONE NAME WHERE YOU CAN BE REACHED List the things that have changed since your application or last recertification such as moved had a baby income etc* If You Are Reapplying For Food Stamp Benefits FS you have the right to turn in file this form the same day you get it. It must have at least your Name Address if you have one and Signature below when you turn it in* If you are eligible you will get FS back to the date you filed* You may be able to get FS quicker if you have little or no income or liquid resources or if your rent and utility expenses are more than your income and liquid resources.

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