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Get NY LDSS-2921 2020-2024

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide Rev. 1/05 CENTER/ OFFICE APPLICATION DATE UNIT ID WORKER ID CASE TYPE SERV. IND CASE NUMBER REGISTRY NUMBER LIFELINE EFFECTIVE DATE CASE NAME DATE ELIGIBILITY APPROVED BY SUPERVISOR PAGE 1 DISTRICT DISPOSITION DENIAL ELIGIBILITY DETERMINED BY WORKER VERS REASON CODE WITHDRAWAL SUFFIX FS CATEGORY LANG SERVICES TRANSACTION TYPE NEW OPENING REOPEN RECERTIFICATION SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION NUMBER REUSE INDICATOR FORM 0F x DATE RECEIVED BY AGENCY EMPLOYED BY SOCIAL SERVICES DISTRICT TA AUTHORIZATION PERIOD FROM PROVIDER AGENCY SPECIFY TO SERVICES AUTHORIZATION PERIOD NEW YORK STATE APPLICATION FOR TEMPORARY ASSISTANCE TA - MEDICAL ASSISTANCE MA - MEDICARE SAVINGS PROGRAM MSP - FOOD STAMP BENEFITS FS - SERVICES S including Foster Care FC - CHILD CARE ASSISTANCE CC 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 application 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-1301 Statewide when completing this application* CHECK EACH PROGRAM YOU OR ANY HOUSEHOLD MEMBER ARE APPLYING FOR DO YOU WANT TO RECEIVE NOTICES IN Temporary Assistance and Medical Assistance Medicare Savings Program Food Stamp Benefits SPANISH AND ENGLISH ENGLISH ONLY WHAT IS YOUR PRIMARY LANGUAGE Services including Foster Care ENGLISH SPANISH Child Care in lieu of TA Child Care Assistance OTHER specify Medical Assistance Emergency Payment Only EMRG DO ANY OF THESE APPLY TO YOU AREA CODE COUNTY STATE ZIP CODE CARE OF NAME Complete if you receive your mail in care of another person MAILING ADDRESS IF DIFFERENT FROM ABOVE APT. NO. CITY AGENCY HELPING APPLICANT/CONTACT PERSON PHONE NUMBER HOW LONG HAVE YOU LIVED AT YOUR PRESENT ADDRESS DIRECTIONS TO HOME YEARS MONTHS IS THIS A SHELTER YES FORMER ADDRESS NO ANOTHER PHONE NAME WHERE YOU CAN BE REACHED If You Are Applying For Food Stamp Benefits FS you have the right to turn in file this application 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. Talk to your worker if you have questions about this. FS APPLICANT/REPRESENTATIVE SIGNATURE X DATE SIGNED Need Child Support No Place To Stay/Homeless Urgent Personal Or Family Problem Fire Or Other Disaster Have No Job Serious Medical Problem Recently Lost Income Pending Eviction No Food HOUSE NO.

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