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 ....
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How to fill out the NY LDSS-3174 online
The NY LDSS-3174 is a recertification form used to verify eligibility for various assistance programs. Completing this form accurately online is essential for maintaining your benefits. This guide provides clear, step-by-step instructions to help users navigate each section of the form effectively.
Follow the steps to fill out the NY LDSS-3174 online correctly.
- Click the ‘Get Form’ button to obtain the form and open it in your editor.
- Begin by filling out the center/office, interview date, unit ID, worker ID, case type, case number, district, and case name in the designated fields.
- Indicate the eligibility determination information, including signature and dates for the person who obtained this information, as well as the reason code and effective date.
- In Section 1, check each program for which you and any household member are recertifying. This includes Public Assistance (PA) and the Supplemental Nutrition Assistance Program (SNAP).
- Provide your personal information in the recipient information section, including first name, last name, address, phone number, and marital status.
- Complete additional sections as relevant, including household information, income details, and other relevant personal circumstances.
- Upon completion, ensure all fields are appropriately filled and review for accuracy.
- Once satisfied, save your changes to the form, and then you may choose to download, print, or share the form.
Complete your NY LDSS-3174 form online today to ensure your benefits remain uninterrupted.
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