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1 ��LDSSStatewide(Rev. /20DO
��LDSSStatewide(Rev. /20DO NOT WRITE IN THSHADED AREAS OF THIS APPLICATION CENTER/ OFFICE APPLICATION DATE UNIT ID WORKER ID CASE TYPE SERV. IND CASE NUMBER REGISTRY NUMBER VERS DISTRICT SUFFIX SNAP SUFFIX CATEGORY LANG NUMBER REUSE INDICATOR EFFECTIVE DATE DISPOSITION SERVICES TRANSACTION TYPE NEW OPENING REOPEN RECERTIFICATION DENIAL REASON CODE WITHDRAWAL ELIGIBILITY DETERMINED BY (WOR KER): DATE ELIGIBILITY APPROVED BY (SUPERVISOR): DATE SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION DATE FORM __________ 0F _____________ x DATE RECEIVED BY AGENCY EMPLOYED BY: SOCIAL SERVICES DISTRICT PROVIDER AGENCY SPECIFY: PA AUTHORIZATION PERIOD MA AUTHORIZATION PERIOD SNAP AUTHORIZATION PERIOD SERVICES AUTHORIZATION PERIOD FROM TO FROM TO FROM TO FROM TO NEW YORK STATE APPLICATION FOR CERTAIN BENEFITS AND SERVICES If you are blind or seriously visually impaired and need this application in an alternative format, you may request one from your social services district.For additional information regarding the types of formats available and how you can request an application in an alternative format, see the instruction book (PUB1301 Statewide)available at www.otda.ny.govor https://www.health.ny.gov/ . I f you are blind or s eriously visually impaired, would you like to receive written notices in an alternative format? Yes No If yes, check the type of format you would like: Large PrintData CD Audio CDBraille, if you assert that none of the oth lternative formats will be equally effective for you If you require another accommodation, please contact your social services district . We are committed to assisting and supporting you in a professional and respectful mannerYouareresponsible fr participating in activitiesincluding work activitiesfor PublicAssistance and the Supplemental Nutrition Assistance Programwhere required, so you can become selfsufficient. Whenever you see “PublicAssistance” or “” on the application, it means Family Assistance” and/or“Safety Net Assistance” We call both rograms Public Assistance” These rograms are meant to assist you only until you can fully support yourself and your family.Please referto the instruction book (PUB1301 Statewide) B ooks 1, 2 and 3 (LDSS - 4148A, LDSS - 4148B, and LDSS - 4148C) when completing this application , and contact your social services district with any questions. When you see on the application, it means MedicaidYou may apply fr MAusing this application only if you are also applying for Public Assistance or the Supplemental Nutrition Assistance Programat the same time. If you wish to only app

2 ly for MA, you can go online at https://
ly for MA, you can go online at https://nystateofhealth.ny.gov/ and/or call 15777for more information or to applyyou may use the MAonlypaper application Form DOHwhich your worker can give youor call MA help line at 12831. If you want to apply only for the Medicare Savings Program (MSP), you must apply wth Form DOHwhich youworker can provide to you.If you have an immediate need for personal care services, you should apply for M A separately using the DOH - 4220 M A application form. 06 02 10 ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THIS APPLILDSSStateev. /20 SECTION 1 CHECK EACHPROGRAMYOU OR ANY HOUSEHOLD MEMBER ARE APPYINGFOR Pub汩cA獳i獴慮捥 䍨ild⁃are楮楥uf P䄠 Suppl敭敮t慬⁎utrition⁁獳i獴慮捥⁐rogra(华A倩 䵥di捡id(M䄩and⁓乁P†††††††† ††† 䵥di捡id(䵁)⁡nd S敲癩捥s(匩,⁩湣l畤in朠F潳ter⁃are(F䌩 Ch楬d C慲攠A獳it慮c(䍃) Em敲g敮捹 A獳i獴慮捥佮l(EM則) SE䍔IO丠2 SECTION DO ANY OF THESE APPLY TO YOU?PregnantVictim of Domestic Violence Need o EstablishNeed Child SupportDrug/Alcohol ProblemFuel r Utility toffNo Place o Stay/HomelessFire r Other DisasterHave No IncomeSerious Medical ProblemPending EvictionNo FoodNeed Foster CareNeed Child Care Problems with English Reasonable Accommodations Other WHAT IS YOUR PRIMARY LANGUAGE? ENGLISH OT䠀ER
s灥cify) 彟彟彟开 卐䅎I午 DO YOU WANT TO RECEIVE NOTICES IN: ENGLISHONLY ENGLISH AND SPANISH S ECTI ON 3 APPLICANT INFORMATION PLEASE PRINT CLEARLY FIRST NAME M.I. LAST NAME MARITAL STATUS PHONE NUMBER ( ) AREA CODE STREET ADDRESS APT. NO. CITY COUNTY STATE ZIPCODE IN C A RE O F NAME ( COMPLETE IF YOU RECEIVE YOUR MAIL IN CARE OF ANOTHER PERSON ) MAILING ADDRESS (IF DIFFERENT FROM ABOVE) APT. NO. CITY COUNTY STATE ZIP CODE HOW LONG HAVE YOU LIVED AT YOUR PRESENT ADDRESS? YEARS MONTHS IS THIS A SHEL T ER? YES NO AN OTHER PHONE WHERE YOU CAN BE REACHED NAME PHONE NUMBER ( ) AREA CODE DIRECTIONS TO CURRENT ADDRESS FORMER ADDRESS APT. NO. CITY COUNTY STATE ZIP CODE IF YOU ARE CURRENTLY WITHOUT A HOME, CHECK HERE AGENCY HE L PING APPLICA N T/CO NTACT PERSON PHONE NUMBER ( ) AREA CODE DO YOU NEED THE MEDICAIDPORTION OF THIS APPLICATION AND THE POTENTIAL RECEIPT OF ANY MEDICAID COVERAGE TO BE KEPT CONFIDENTIAL? SECTION If You Are Applying For SNou canle an application the day you get it. In order to file a SNAP application, it must have, at minimum, your name, address (if you have one) and signature below. You must complete the application process, including signing the last page of the aplication anng interviewed. If eligible, you will get SNAP benefits back to the date you filed the application.You must be told, within 30 days of the date you turned in (filed) your pplication for SNAP enefits, if your pplication is approved oied.

3 our household has little or no income o
our household has little or no income or liquid resources, or if your rent and utility expenses are more than your income and liquid resources,you may be eligible to get SNAP benefits within five calendar days of the date you fileIf you aresident f aninstitution and are applying for both Supplemental Security Income (SSI) and SNAP benefits prior to leaving the institution, the filing date of the application is the date you leave the institution. SNAP APPLICANT/REPRESENTATIVE SIGNAT U RE X DATE S I GNED ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE Does This Person(Including MinorChildren) Buy Food Prepare Mealsith You? Highest School Grade Completed RI LN Fist Name, Mile Inti, Lst Name This ersonpplying or: Date of Birth: (mm/dd/y Sex (M/F) Gender Identity (Opt (Male, Female, NonBinaryX, Transgender, Different Identity [please describe]) Relationship to yu: S o c i a l S e c u r i t y N u m b e r of Applyng Houshold Members (See instruction book, PUB1301 Statewide, lk to your s o cial services district ) PA SNAP MA CC FC S EMRG YES NO 01 SELF 02 03 04 05 06 07 08 PLEASE LIST MAIDEN OR OTHER NAMES BY WHICH YOU OR ANYONE IN YOUR HOUSEHOLD HAVEBEEN KNOWN Line No. ONC FIRST NAME M.I. LAST NAME Line No. ONC FIRST NAME M.I. LAST NAME IS ANYONE SANCTIONED? YES NO IF YES, WHO REASON END DATE NON - APPLICANT INFORMATION LEGALLY RESPONSIBLE FOR CONTRIBUTION/ CHECK I F MEMBER LN FIRST NAME LAST NAME YES NO WHOM? DEEMED INCOME OF SNAP H OUSEHOLD NONCITIZEN WITH SATISFACTORY IMMIGRATION STATUSINFORMATION INDIVIDUAL EDUCATION CONSIDER NON - CITIZEN STATUS STATUS ADJUSTED DATE OF ENTRY/STATUS APPLIED FOR CITIZENSHIP SPONSORED LN DEGREE RECEIVED LN DEGREE REIVED RCA/RMAREFERRAL LN YES NO MONTH DAY YEAR YES NO YES NO 01 05 02 06 03 07 04 08 S ECTI O N 6 – HOUSEHOLD INFORMATION – List everybod y who live s with you, even if they are not applying wit h y o u. Li st yourself o n the first line. ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THIS APPLILDSSStateev. /20 LN SECTION 7 RACE/ETHNICITProviding this information is voluntary . It will not affect the eligibility of tsons appyingor the level of benefits receive . The reason for requesting this information is to sure that program benefits are distributed without regard to race, color, or national origin. CLIENT IDENTIFIC

4 ATION NUMBER ENTER APPROPRIATE COD HISPA
ATION NUMBER ENTER APPROPRIATE COD HISPANIOR LATINONATIVE AMERICAN OR ALASKAN NATIVEASIANBLACK OR AFRICAN AMERICANNATIVE HAWAIIAN OR PACIFIC ISLANDERWHITE U UNKNOWN (MA ONLY ) REL SSN SFUI MS SI LA EM CI EL ENTER Y (YES) OR N (NO) FOR HISPANIC OR LATINO TER Y (YS) OR N (NO) FOR EACH RACE H I A B P W U 01 02 03 04 05 06 07 08 ANTICIPATED FUTURE ACT I O N CA SE TYPE R ELAT ED CASE NUMBERS CONSIDER LINE NO. CODE DATE Relationship Filing Unit Legally Responsible Relative Single Economic Unit SNAPHousehold Composition SNAPAged/Disabled Individual Photo ID AFIS nly) CBIC/PIN FI/OCA lth Insurance SERVICE ELIGIBILITY PROCESS CODE SFUI CODE SFUI CODE SFUI CODE SFUI CODE NEEDED REFERRALS COMPLETED Legal Services SSA NYSoH C hronic Care/SSI - Related MA - Only Medicare Savings Program REQUESTED DOCUMENTATION IN FILE Photo ID Birth V erif ica tion Marriage License Social Security Card Code 9 Resolut ion Immigration Status Multfix/Coop Case Notice (Single Economic Unit Q u e s tionna ir e) ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE Please read this entire page carefully before completing it . If you hav e questions , see the instruction book (PUB - 1301 Statewide) or talk to your social ser v i ces district . SE CTION 8 – CITIZENSHIP / NON - CITIZEN WITH SATISFACTORY IMMIGRATION STATUS SECTION 9 – CERTIFICATION LIST EVERYONE WHO IS APPLYING OR WHO IS REQUIRED TO APPLY.You have to fill out Sections 8 and 9 if you are:Applying for Child Care Assistce nly, butyou need to fill out the information only for the children who would be receiving Child Care Services.Applying for Foster Care only, but you need to fill out the information only forthechildren who would be receiving Foster Care.Applyingor other Sericesunder certain circumstances. Some social services programs require that you certify that you are a U nited States citizen, Native American or nationalof the U.S., or acitizenwith satisfactory immigration status. Other programs You USTsign the Certification below only if you are a United Statescitizen, Native American or national

5 of the United States, or acitizen with
of the United States, or acitizen with satisfactory immigration status, andyou are applying for: PublicAssistance (where there are cldren in theehold or a member of the household is pregnant), The Supplemental Nutrition Assistance Program Medicaidexceptif the applicant is pregnant), or Child Care Assistance (certification is needed for the children only), orFoster Car(certificatin isneeded for the children only), orOther ervices under certain circumstancesEmergency Payment Assistance An adult household member or authorized representative may sign for all household members. Example: A parentwithoutsatisfacry citizatus may sign for childwithsatisfactory citizenstatus. N EEDED R EFERRALS C OMPLETED Systematic Alien VerificationforEntitlements (SAVE) An application for SNAPmust list all persons living in the SNAPd. An applicaton formust list all children for whom you are applying, their and all parents of those children who live together. If you do not check whether a listed person is a United Statescitizennationalof or an citizen wita satisfactory migratistatusor provide an U.S. Citizenship and Immigration Services (USCIS) number (Alien egistration umberor acitizen(if applicable), that person will not be given assistance and the rmaining membes of the house h old will receive r educed benefits. If you are a Native American, check citizen/national. SIGN* AND DATE THE BOX BELOW FOR EACH APPLICANT . In the case o f a n applying non - citizen with a satisfactory immigration status, checkogram(s) or which each pplying noncitizehas satisfactory immigration status. See the instruction book, Pub1301 Statewide. LN FIRST NAME MI LAST NAME heckeither "CITIZEN / NATIONAL" or NONCITIZEN foreachperson. USCIS NUMBER (ALIEN REGITRATION NUMBENONCITIZN NUMBER (If Applicable) CERTIFICATION DATE PA S N A P MA CC F C S E M R G 01 䍉TI娀E丯 N䅔ION䅌 乏N C䥔䥚EN Si杮⁎慭e 䍉TI娀E丯 N䅔ION䅌 乏N C䥔䥚EN Si杮⁎慭e 䍉TI娀E丯 N䅔IN䅌 乏N C䥔䥚EN Si杮⁎慭e 䍉TI娀E丯 N䅔ION䅌 乏N C䥔䥚EN Si杮⁎慭e 䍉TI娀E丯 N䅔ION䅌 乏N C䥔䥚EN Si杮⁎慭e 䍉TI娀E丯 N䅔ON䅌 乏N I娀䕎 Si杮⁎慭e 䍉TI娀E丯 N䅔ION䅌 乏N C䥔䥚EN Si杮⁎慭e 䍉TI娀E丯 N䅔ION䅌 乏N C䥔䥚EN 杮⁎慭e By checking a box above and by signing the certifi c atio n in Sect i on 9, I hereby certify, under pen alty of perjury, that I, and/or the person ( s ) for whom I am signing, am a United States citizen, Native American or national of the UnitedStates, or acitizen with satisfactory immigrationstatus. I undestand that sining this Certfication may result in information about applying members of my household being submitted to the United States Citizenship and Immigration Services for verification of citizenstatus, if applicable. The use or disclosure otheinformaton above is retricted to personsand organizations directly connected with the verification of citizenshipstatusand the administration or enforcement of the provisions of the PublicAssistance, Supplemental Nutrition AssistanceMedicaidChild Care Asistance, Fostr Care and Services Pro

6 grams. A person who wishes to si
grams. A person who wishes to sign the Certification but cannot write may make an "X" on the line in front of a witness. Th e witness must sign below. I witnessed the marks made in lines: ____ _ ,___ ___,_____ _ _,______,_____ , _____ Signatur e of witness: _____________________________________ Date Signed: ____________________ * ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THIS APPLILDSSStateev. /20 SECTION 10 INFORMATIONREGARDING REFERRALTO THE CHILD SUPPORT ENFORCEMENT UNIT If you are applyingonlyforchild careistance, you ae not required to pursue child support and do not have to fill out this section. If you are applying for Medicaidin addition to Public Assistanceor the Supplemental Nutrition Assistance Program, you may have to help us obtin edical suport for yourslf and your applying children.Answer the following questions to determine if you need to complete this sectionInclude yourself, as appropriateAre youapplying for an individual under the ageof 21 who was born out of welockand for egahas not been established?Yes No Are you applying for an individual under the age of 21 who has an absent noncustodial parentYes No u do not need to coplete is section if ou answered “No” to both of these questions. Go to Section 11.You must complete this section if you answered “Yes” to either or both of these questions.Provide the names of all individuals under theof 21for whom you are aplying and any informaion you currently have about those individuals’ noncustodial parents or allegedarentAre you under the age of 21? Yes If you answered “Yes” to this questionrovide the information for your noncustodialparent(s) or arent(s) As a condition of obtaining assistance, you are required to assign certain rights related to support, as described in the Notices, Assignments, Authorizations, anConsentssection at the endof this application.ou will be provided ith the LDSSform, “Referral for Child Support erves,” to complete and return to the Child Support Enforcement UnExcept in situations of domestic violence or othergood cause, as a condtion of obtaining assistanceyou are required to cooperate with the Child Support Enforcement Unit to locate any noncustodial parent or pare; establish for each individual under the age of 21 born out of wedlock;and establish, modifyand/or enforce orders of support. You also will be provided with the LDSSform, “Notice of Responsibilities and Rights for Support,”which eplain y our resp onsibilities and your rights if you do not cooperate with the Child S upport E nforcement Uni t . NAME OF INDIVIDUAL UNDER AGE NONCUSTODIAL PARENT OR REN’S NAME AND ADDRESS NONCUSTO DIAL PARENT OR AREN’S DATE OF BIRTH NONCUSTIAL PARENT OR AREN SOCIAL SECURITY NUMBER MONTH DAY YE AR A. B. C. D. E. REQUESTED DOCUMENTATION IN FILE

7 Acknowledg ment of P a r e n t a
Acknowledg ment of P a r e n t a g e o r Paternity Child Support Order Good Cause Form (L DSS - 427 9) IV - D Att estation (LDSS - 4 281) Death Cert ificate Di vorc e Decree VA Benefits Orde r o f Filia ti on/ Paternity / P a r e n t a g e Birth Certificate NEEDED REFERRALS COMPLETED CTHP CAP R eferral for Child Support Service s (LD SS - 5 145 ) P a r e n t a g e / Paternity CONSIDER Health Insurance of Non stodal Pt/Abse Spouse Child Health Plus TASA Petition to Family Court SSI/SSA ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE SECTION 11 – T AX FILING/ DEPENDENT STATUS - Please select the tax status for each individual living in the hou sehold. TAX STATUS FIRST NAMEIDDLE INITIALLAST NAMESINGLEMARRIED FILING JOINTLYMARRIED FILING SINGLEHEAD OHOUSEHOL(WITH QUALIFYING INDIVIDUALQUALFIYING WIDOW(ER) WITH DEPENDENT CHILDDEPENDENT AND WILL BE FILING TAXESWILL NOTFILING TAXES Tax dependents noliving in the household. Please list any taxdependents who do not live with you and are claimed by you or anyone in your household. If you do not file axesyou can skip this question . NAME OF TAX DEPENDENTNAME OF TAX FILER FIRST NAMEMIDDLE INITLAST NAMFIRST NAMEMIDDLE INITIALLAST NAME SECTION 1 2 – ABSENT/DECEASED SPOUSE INFORMATI ON – If the spouse of a nyone applying lives someplace else or is deceased, please indicate below. NAME OF PERSON APPLYIN G NAME OF S POUSE DATE OF SPOUSE’S BIRTH DAT E OF SPOUS E’S DEATH, IF APPLICABLE SPOUSE’S SOCIAL SECURITY NUMBER SPOUSE’S ADDRES S, IF AP PLICABLE CITY COUNTY STATE ZIP CODE SECTION 1 3 – ABSENT CHILD INFORMATION – If anyone applying has a child u n der th e age of 2 1 living someplace else, plea se indicat e below. NAME OF PERSON APPLYING NAME OF ABSENT CHILD DATE OF BIRTH ADDRESSOF CHILD(STREET, ITY, COUNTY, STATEAND ZIP CODE) ESTABLISHED? DO YOUPAY CHILDSUPPORT? Yes No Yes N o SECTION 1 4 – TEEN P ARENT INFORMATION TEEN PARENT TEEN PARENT CHILDREN Is there a parent under theageen parent”)in the household? Yes Name_____________________________________________ LN NO. _________________ LN NO. __ ___________________ Does the teen parent’s child live in the household? Yes No Name of teenparent’s child ____________________________________________ LN NO. Marital S tatu s High Schoo l Diploma / High Sc hool Eq uivalent ? LN NO. Marital Statu High School Diploma/High School Equivalent ��PAGE DO NOT WRITE IN THE SHAD

8 ED AREAS OF THIS APPLILDSSStateev. /20
ED AREAS OF THIS APPLILDSSStateev. /20 SECTION 1NCOME INFORMATIO Indicate if you or anyone who lives with youreceivesmoney from: YES NO WHO AMOUNT/VALUE FREQUENCY WHO AMOUNT/VALUE FREQ UENCY CD INCOME Unemp l oyment Insurance Benefits 1 49 LN No. SOURCE C ODE MOUNT PERIOD Supplemental Security Inc ome (SSI) Benefits (State and Federal Total) 2 45 Social Security Disability (SSD) Bene f its 3 42 Social Sec urity Dependent Benefits 4 Social Secur i ty Survivor’s Benefits 5 43 Social Secur i ty Re tirement Benefits 6 44 Railroad Retirement Benefits 7 38 Retirement Benefits (Pensions) 8 39 D ividends/Interes t from Stocks, Bonds, Savings, etc. 9 03 Wor kers’ Compensation 1 0 59 NYS Disability Benefits 1 1 33 Veteran’ s Pension/Bene f its/Aid and Attendance 1 2 55 Public Assistance Grant 1 3 37 GI D ependency Allotm e nts 1 4 10 Education Grants or Loa ns 1 5 Contributions/Gifts (Received) 1 6 Foster Care Payments ( Received ) 1 7 Child Support Payments (Received) Received From:_______________________________________ 1 8 06 Spousal Support (Received) 1 9 02 Private Disability InsuranceHealth/AccidentInsurance Policy Income 2 0 No - Fault Insuran c e Benefits 2 1 50 Union Benefits ( i ncluding Strike Benefits) 2 2 L o ans, Other than E ducat ion (Received) 2 3 Income from a Trust ( i ncluding income you are currently entitled to receive, or were entitled to receive inthe past, thahas not been distributed) 2 4 Training Allotments /Stipends 2 5 31 Re n tal Income (Rece i ved) 2 6 14 Boarders/Lodgers Income ( Received) 2 7 Other Income (Please Specify) CONS I D E R Ch il d Support Disregard/Pass - Through Explained Budgeted SNAP Aged/Disabled Indicator �9 �9 Disa bili ty Review Recep tion and Placement Gra(SNAP Only) Refugee Matching Grant ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE Ded uctions : Certa i n types of Medicaid budgeting allow applicants/recipients to reduce their countable ncome with deducions that they take on their federal taxes. These are specific expenses that the Internal Revenue Serv

9 ice (IRS) allows people to deduct to red
ice (IRS) allows people to deduct to reduce their t xable income. Only record deductions here if you will claim them on the current years tax return. YES NO WHO AMOUNT/VALUE & FREQUENCY WHO AMOUNT/VALUE REQUENCY Educator expenses Individual Retirement Account (IRA) deduction 2 Student loan interest deduction Tuition and fees 4 Certain business expe n ses (reservists, artis ts, fee - based government officials) 5 Health svings account deduction Job - related mo v ing e xpenses 7 Deductible part of self - employment (S/E) tax 8 S/E, SIMPLE & qualified plans S/E health insurance deducti on 10 Penalty on early withdrawal of savings Alimony paid 12 Domestic production activities deduction Additional adjustments added on line 36 (IRS Form 1040 only) 14 Archer SA deduction Other Adjustment (Please Specify) SECTIO N 1 6 – STE P PARENT/ NON - CITIZEN WITH SATISFACTORY IMMIGRATION STATUS SPONSOR INFORMATIO N Answer all q uestions listed below . Does the steprentof any children who live with you have any resources or receive income ofany ki nd? YES NO WHO ? NEEDED REFERRAL COMPLETED UIB Is anyone in your household a ncitizen with isfactory immigration status who was sponsored for a dmission into the U.S.? NAME OF SPONSOR: PHONE NO.: ADDRES ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THIS APPLILDSSStateev. /20 SECTION 1EMPLOYMENT INFORMATION I am currently: loyed s敬fy敤 畮敭灬潹敤 Gross Income $ ________________ (Include wages, salary, overtime pay, commissions, and tips) ours orked Monthly ______________ Paid: W敥kly††† ee歬礠††† 䵯湴桬y††††D慹f⁴桥⁷e敫⁰慩d Employer’s N am e a nd Address: 1 ___________________ _________ __________________ Phone No. __________________

10 __________________________ _______
__________________________ _______ _____________ Is anyone else who lives with you currently: 敭灬潹敤 s敬f 敭灬潹敤 Who : _________________ __ ___ ___________________________ Gross Income $ ________________ Hours Worked Monthly _________________ Paid: W敥kly†† ee歬礠††† 䵯湴桬y††††D慹f⁴桥⁷e敫⁰慩d Employer’s Name and Address: _ _ _ _________________ ___ __ _____________________ Phone No. _______ _________ __ ______________________________________________ Is health insuranc e avail able through y ou r employer? Y敳 Does anyone who lives with you have health insurance wi t h an employer? Who: ____________________________ _________ ____ 3 Name of Insurance Company: _________________________________________________________ Do you or anyone who lives with you havechild or dependent care expenses due t o e mployment ? Y敳 Who: _______________________________________ 4 Do you or anyone who lives with you have other employmentrelated exp enses? Y敳 ho: _________________________________________ 5 REQUESTED DOCUMENTATION IN F ILE CINTRAK/RFIIRCS 1099 Employment Verification Income Tax Return Self - Employment Worksheet Wage Stubs Work Regis trat ion Form De pendent/Ch ild Car e For m/ Statement Approval of Informal C hild Care Provid er CONSIDER Limited EnglishProfncy rn敤 I湣潭攠T慸⁃re摩t (se攠P啂4㜸6) Ex灬慩湩湧 P敲i潤ic R数潲ti湧⁒e煵irem敮ts Net Lossof Cash Incom P.A.S.S. Income Amo unt and Sour ce s �9 Employment Sanctions �9 Tempo rary Employment �9 Disability Revi ew �9 Individ ual D evel o p m e nt Acc ou nt (IDA) �9 Voluntary Quit NEEDED REFERRALS COMPLETED CAP Disability Employment TPH I/CO BRA UIB Workers ’ Compe nsati on Drug/Alcohol Domestic Vio lence Refuge e Cash Assistance ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE If not employed, n was the last tiu or anyone who lives with you worked? Who : _________________________________________ When: __________________________ Whe re: __________ __ ______________________________________________________________ 6 Why did you (they) stop workin________________________________________________ Did you or anyone living with you file for unemployment? Yes No If yes, wh_______________________ When?: ________________ Status of filing: pproved DeniePending Are you or is anyone who lives wit h you participating in a strike? Y敳 Who: _________________________________________ Whethe strike began___________________________ 7 Are you or is anyone who li v e s with you a migra nt or seasonal farm worker? Y敳 Who: _________________________________________

11 8 Do you or any other adult who l
8 Do you or any other adult who lives withyou have any dical conditions that limit the ability to work or the type of work that can be pe rmed?Yes Who: __________________________________ __ Descri be Limitations: _____________________________________________________________ _____________________________________________________________ 9 Could you accept a job today? Y敳 If not, why? ________________________________________________________________ What type ofwork would you like to do?_________________________________________ _____________________________________________________________________________ CHILD/DEPEN DENT CARE E X P ENSES W ho Pays Amount Name Age Care Provider $ $ $ $ $ $ $ $ ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THIS APPLILDSSStateev. /20 SECTION 1 8 – EDUC ATION/TRAINING What is your highest level of education completed? __ Less than high school diploma If so, last grade complete Completion of an Individualized Education Plan (IEP) High scdiploma or GeneraEquivalencyDiploma (GED) or Test AssessinSecondary Completion (TASC™) Associates Degree (2year college degree) __ Bachelors Degree (4year collegree) or higher es anyone else in the household have a high school diplomaGeneral Equivalency Diploma (GED) or Test Assessing Secondary Completion (TASC™),or hier level of education? If yes, who: _______________ Degree attained:____________ Da te completed: _________________ Yes Indicate if you or anyone who lives with you who is applying for or gettssistance Is o r has been in any training program? Yes Who Where Program Dates attended _______________________________ Datecompted _______________________________ Is 16 years of age or older and isattendi hool or college? es Who Where s under 16 years of age and is attending school? Yes Who School Who School Who School Who School REQUESTEDDOCUMENTATIOIN FILE hool Attendance Verification LDSS3708 Edutional Grant Worksheet Child Care Statement EDED REFERRALS COMPLETED Support ive S er vices CONSIDER YES NO Does anyone 18 through 4 9 who is attending college hatime ormore m eet t he SNAP student eligibility requiremen t? Does an yone pay for child or dependent care o atschooor training? Is there a 16 19 yearold parent who does not have a high schoolor equivalenc y diploma and who is not atte nding scho ol? Is a nyone in

12 training? Are any oth er support
training? Are any oth er supportive se rvices appropriate? Are the re a n y tr a i n i ng rel at ed expenses? ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE SECTION 1 9 – RESOURCES INFORMATION Indiif you or anyone ho lives with you who is applying: YES NO WHO AMOUNT/VALUE WHO AMOUNT/VALUE NEEDED REFERRAL COMPETED Has cash available 1 Legal H as a checking account(s) 2 Resource Has a savings account(s) or certif i c a t e (s) of deposi t 3 Has a credit union account(s) 4 Has life insurance 5 Has title or registration to a motor vehicle(s) or other vehicle(s):ar ________ Make/Model ____________________________Year ________ Make/Model ______________________ Other__________________________________________ Has stocks, bonds, certificates or mutual funds 7 Has savings bonds 8 Has an IRA, Keogh, 401(k)or deferred compensation account(s) 9 Has an i r r e v ocable burial tru s t 10 Has a burial fund 11 Has a bu rial space 12 Has t h e i r own home 13 Has real estate, including incproducing non - income - producing property 14 Is eligible for an income tax r e f u nd 15 Ha s an annu ity 16 Is the beneficiary of a trust 17 Expects to receive a trust fund, lawsuit settlement, inheritance or income fr om any other s ou rces 18 Has an “in trust” account(s) 19 Has a safe depos i t b o x (es) 20 Has reso urces other than those listed above 21 s anyone (including your spouse, even if not applying or living with you) given away any cash, or sd/transferred any real estate, income or personal property in the past 36 m o n t h s? 22 Has anyo ne ( including your spouse, even if not applying or liv ing with you) ever created a trust in the past or transferred any assets to a trust within the past0 months? If yes, when? _______________________________________ V E H ICLE INFORMATION YR. MAK MODEL OWNER’S NAME AMOUNT OWED DA VALUE EXEMPT LIEN HOLDER ACCOUNT NO. YES* NO $ $ $ $ *IF EX EMPT, WHY? LIFE INSURANCE FACE AMOUNT CASH VALUE REQUESTED DOCUMENTAT ION IN FILE Reso urce Check list Mar ke t Value DMV Clearance Bank S tatement Ass ignment of Proceeds Car/Vehic le T i tle Car/Ve cle Registration (Older M odels) Bank Clearance RFI/OCA 1099 CONSIDER Childre n’s Resour ces Lump Sum Boats, Cam pers, S nowmo bi les �9 Individual Development Accoun t (IDA) �9 Exemp t Vehicles ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THI

13 S APPLILDSSStateev. /20 SECTION 20 ME
S APPLILDSSStateev. /20 SECTION 20 MEDICAL INFORMATION Indicate if you or anyone who lives w i t h y ou who is applyin g: YE S NO IF YES, WHO Has any medical bills or medica lly - related expenses 1 Is on Medicaid with aspenddown Has health or hospital/accident insurance (includisurance from employer) POLICY NO.: AMOUNT: F REQUENCY OF PAY MENT: Has health insurance available through employer INSURANCE COM PANY NAME: as Medicare (red, white, and blue card) WHO IS COVERED: ealth attendantealth aide EFFECTIVE DATE: Is blind, sick or disabled 7 Is the answer to question 7 in this section consistent w ith Section 17 ing if the applicant or any other adult who lives in the household have edical conditions that limit their ability to work or the type of work that they can perform? Is a child with a developmental disability 8 Is in a hospital, nu rs ing home or other medical institution 9 Has paid or unpaid al bills within 3hs precedingthe month of this application Is or was drug or alcohol dependent Needs home care /personal car e 12 Is on SSI or has ever applied for SSI 13 Is pregnant If prt, due date: _____________________________ Expected number of birth s : _________________________ Receives treatment from a drug abuse or alcohol t reatment progr am 1 5 Has not been able to work for at least 12 months because o f disability or illness Has daily activity limi ted because of a disability or illness that has lasted or will last at least 12 months 1 7 Has been in a car accident or work - related accident in the past two years 1 8 s had agovernment agency (public program) besides Medicaidr Medicare any of your medical bills If yes, what agency _____________________ 19 ill billing an other health insurance cause harm to your physical or emotional health or y, and/or will itinterfer e with the privacy and confidentiality of your application for or receipt of Medicaid? 20 REQUESTED DOC UMEN T ATIO N I N FILE Pregnancy Statement Med/Psych Statement Drug/Alcohol Screening (LDSS - 4571) Drug/Alco hol Statem ent Paid or Unp aid Medica l Bills SS I Application Verification ( PA ONLY) CONSIDER D/SSI Related SN AP Aged/Disabl ed I n dica t o r �9 SNA P Medical Deduction �9 TPHI Reimbursement �9 Buy - In Eligibility Kreiger (LDSS - 3664) �9 Domestic Violence �9 SS I Referral �9 E arned Inco me Cred it DED REFERRALS COMPLETED SSI (D - C AP) Disabil ity Interview (LDSS - 1151) Me dica l Rep o r t (LDSS - 48 6, 486t) Disability Report AD TPHI ACCES - VR CTHP Family Pl

14 anning SSA (RS DI) Vet
anning SSA (RS DI) Veteran’s Benefits eteras Counseling Child Health Plu COBRA Eligibility Nurse’s Aide Service me Car NYSoH MA - Only (DOH - 4220) SSI - Related/Chronic Care (DOH 4220 with Supplement A) LDSS - 45 26 o r local equival ent ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE RETROACTIVE MEDICAID WHO DATE RECURRING MEDICAL EXPENSES WHO AMOUNT $ M EDICAL BILLS: YES NO TPHI: YES NO HEALTH P LAN SELECTION M ost people enrolled in Medicaid are required to join a managed care health p l a n unless they are in a n exe mpt category . Use this section to c hoose a health plan. If you do not know what health plans are available, ask your worke r or call 1 - 8 00 - 505 - 5678. ame of Plan You Are Enrolling In Last Name First Name Date f Birth mm/dd Sex M/F ID# (from Mediaid Card if you have one) Social Security # (optionalif pregnant) Primary Care Provider (PCP) or Health Center (check box ifcurrent prov ider) Name andD# of OB/GYN (check box if current provider) S ECTI O N 2 1 – SHELTER REQUESTED DOCUMENTATION IN FILE La ndlord Statement Rent Receipt Tenant of Record Customer o f Record Voluntary Res tr ict Mandatory Restrict Subsidized Housing Mortgage/Title Se a r c h Section 8 Le ase o r St atement from Section 8 Office Property Lie n Shelter/Utility Repayment Agreement CONSIDER Utility and/or Fuel Restrict Utility Gu ar antee HEAP �9 Subsidized Housing May Show Total Rent, NOT Client Amount �9 F oster Care - Relate d Ad d itio nal Allowances �9 SNAP Household Co mposition Rules SNAP Aged/Disabled Indicator Real Property Tax Credit AIDS/HIV Emergency Sh elter Allowanc e Property Lien �9 If Shelter Expenses/Living Quarters Are Shared by More than One Household HAT IS YOUR LANDLORD’S NAME? ______________________________________________________________________ WHAT IS YOUR LANDLOR D’S ADDRESS? _____________________________________________________________________ _____________________________________________________________ _________________________________________________________________ WHAT IS YOUR LANDLORD’S PHONE NUMBER? _________________________________________________________ YES NO IF YE OUNT you or anyoe who lives with youhave a rent, mortgage or other shelter expense? $ Do you or anyone who lives with you havea heat bill separate rom your rent other shelter expense? $ SHELTER COSTS MONTHLY ACTU AL COST A. Room and Board B. Rent C. Trailer ot R D. rtgage Payment 1. Principal 2. Interest 3. Property Tax ncl

15 uding School Tax) 4. Homeowner
uding School Tax) 4. Homeowner’s Insuranc ncl. Fire I nsura nc e) 5. Taxes ncluded in Mortgage (Escrow Payment) 6. sessments (Se wer, etc. ) E . T ot al Mortgage Payment (Line 1 - 6) TOTAL (Lines A ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THIS APPLILDSSStateev. /20 SECTION 21 – SHELTER (CONT . ) Do r anyone who livewith yohave the following expenses separate from your rent or other shelter expense? YES NO IF YES, AMOUNT Electricity(for needs other than heat; exame: lights, cooking, hot water, etc.) $ Natural Gas(for needs otherheat; example: cking, hot water, etc.) $ Water $ Air tioning $ Propane (for needs other than heat) 5 $ Sewer $ Tras $ OtherUtilities andExpenses 8 Specify ____ ______________ $ Do you live in public housing? Do ive in Section 8or other subsidized housing? Do you live in a drug/alcohol treatment facility? *Check Primary Heat Type: Natural GaOilPSC Electric CoalOther ________________________ 䬀敲os敮e 灡湥 Mun楣楰a氠 散t 物c W潯d ADDITIONAL INFORMATION SECTION 2 2 – OTHER EXPENSES Indicate if you or anyone who lives with you who i s applying: YES NO IF YES, OUNT HOW OFTEN PAID LEGALLY OBLIGATED CHILD IN SNAP HH Pays child suppor t 1 $ YES N O Y ES N O Pay s spousal support 2 $ Pa ys for child ca re 3 $ Pays for dependent care 4 $ Pays tuitionfees, or other educational expenses $ Has additional expenses (Example: car payment, car insurance paycredit card paymts,other loan payments, etc.) Specify: _______________________________ $ Do you or anyone who lives with you who is applying oweat least fouronthsof support for a child under the 7 YES NO MONTHLY EXPENSES MONTHLY ACTUAL CO ST NAME OF DEA LER ACCOUNT NUM BER IN WHOSE NAMEIS BILL? (CUSTOMER OF RECORD) WHO IS THE TENANT OF REC ORD? Heat* B. Electr icit y (fo r c o oking, l ights, hot water) C. Gas (for cooking, hot water) D. Liquid Propane Gas E. O ther Utili ties or Expenses F.r Conditioni G. Utility Installation Fees H. Sewer I. Trash Water ��LDSSStatewide(Rev. /20DO NOT WRITEIN THE SHED AREAS OF THIS APPLICATIONPAGE SECTI O N 2 3 – OTHER INFORMA T ION you buy or plan to buy meals from deliveryor communal dining service? YES NO Are you able to cook or prepare meals at YES NO VETERAN STATUS VETERAN CODE Have you or anyone in your household even in the U.S. mlitar ho? ________________________________________ YES

16 NO Has your spouse ever been in the
NO Has your spouse ever been in the U.S. military? 11 YES NO Is anyone in your usehold a dependent of someone who is or was in the U.S. military? Who? _____________________________ YES NO Do you or does anyone who lives with you receive assistance or services now ? YES NO 13 IF YESWHOTYPE OF SISTANCE LOCATION RECEIVED DATES RECEIVED Have you or an y o n e who lives with y o u rec eive d assistance or services in the pas t ? YES NO 1 4 IF YESWHO (Please list all previous names) TYPE OF ASSISTANCE LOCATION RECEIVED TES RECEIVED NEEDED REFERRALS COMPLETED CONSIDER Services SNADependent Care Deductions UIB R INFORMATION (CONT.) YES NO WHO Have you or anyone who lives with you who is applying moved into this county from another New York Sta county wiin the past two months? Have youor anyone who lives with you ever been found lty f anbeen squalified for PublicAssistance and/or the Supplemental Nutrition Assistance Program SNAPbecause of frantentional rogram lation? ve you or anyone who lives with you received benefit for which they were not entitled, wich not bn fully repaid to this or another agency? Have you or any member of your household been convicted of makinga fraudulent statement o representaon of residence in order to receive Public Assistance in two or more states? Haveyouor aember your household been convicted of fraudulently receiving duplicate SNAP Benefits in any state after September 22, 1996? ve you or any member oyour household been convicted of buying or selling SNAP Benefits for a combined amount ofover0 or me after September 22, 1996? Have you or any member of your household been convicted of trading SNAP benefits for firearms, ammunition or explosis, or drugs? Are you or any member of your household fleeing to avoid prosecutiontodyconfinent after conviction of felonyor attempted felony and actively being pursued by law enforcemen Areyouor any member of your householdvioling probation or paroleaccording toa court order PROPERTY TRANSFER STATUS I h ave I h ave no t �� sold, transferred or given away any of my property to anyone to get PublicAssistance or SNAPenefits. REQUESTED DOCUMENTATION IN FI ucatial Grant Worksheet Child/Dependent Care Statement Recoupments Outstanding Overpament PendinDisqualification ��PAGE DO NOT WRITE IN THE SHADED AREAS OF THIS APPLILDSSStateev. /20 IF TOTAL EXPENSES (INCLUDING EXPENSES NOT USED IN THE BUDGET DETERMINATION) EXCEED INCOME (INCLUDING PA GRANT), PLORE HOW THE HOUSEHOLD IS MEETING ITS OBLIGATIONS. EMERGENCY CASH ASSIS Is there an imediatot, hy Actual Exp enses $ Actual Income $ = D ifference $ YES NO Does Client Receive Contribution Towards Difference I Yes, From Whom? _____ ___________________________ NO

17 TES/COMMENTS CONSIDER Actual Expen
TES/COMMENTS CONSIDER Actual Expenses, including: shelter, fuel/utility costs, telep hone costs, etc. Actual Shel ter �9 Act ual Fue l/Uti li ty Costs �9 Telephone Expenses �9 Ca r Expenses Fu rniture/Appliance Rental Cable TV Tu i t i o n �9 O ut - of - Pocket Medical Expenses ��LDSSStatewide(Rev. /20PAGE NOTICESASSIGNMENTS, AUTHORIZATIONS, and CONSENTS COLLECTION AND USE OF SOCIAL SECURITY NUMBERSThe collection of Social Security Numbers (is authorized for each hold member with rspectto the Supplemental Nutrition Assistance Program (SNAP), pursuant to the Food and Nutrition Act of 2008 (as amended. Anyoneapplying forSNAP must prode an SSN in order to receive benefits.If you or anyone applying does noSSN, that prson mustapplfor aSSN with the Social Security Administration (visit www.SSA.gov or call 8007721213 With respect to allother programs for which ts application form requires aSSN, the collection of SSNs is also mandatod is authorized nder one or more of the following sections of law: Section 205(c) of the Social Security Act (42 U.S. Code 405), Section 1137 of the Social Security Act (42 U. Code 1320b7) and Section 7(a)(2) of the Privacy Act of 1974. See the intion book (PUB01 Statewide) or talk to your social services district if you have questions.The information we collect will be used to determinewhether yourhousehold is igible or continues to be eligible for assistance or benefits. The informawill be used to heck identity, to verify earned and unearnedincome, to determine if absent parents can receive health insurance coverage for applicants or recipients, to detmine if applicants or recipients can obtain child or spousal support, and termine if appliants or recipients can receive money or other help. We will verify this information through computer matching programs. This information will also be used tmonitor compliance with program regulations and for program management.using the inforationyougive us in this way, the state wiluse the information to prepare statistics about all of the people receiving benefits from the HomeEnergy Assistce Program (HEAP) (see below).This information may be disclosed to othete and federal aencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. Information collected withespect to applicants for and recipients of Family Assistance and Safety Neistance, includig SSNs, may be used to assist in the formation of jury pools. If a SNAP claim arises against your household, the information on this application, including aSSNs, may be referred to federal and state agencies, aswell as private collection agenies, for claims collection action.SSNs of ineligible household members will also be used and disclosed in the manner above.Besides using theinformation ygive us in this way, the State also uses the information to prepare statiabout all the pople receiving benefits fromHEAP. The information is usedfor quality control by the State to make sure social servicesdistrictsare doing the best job thecan. It is used to verify your energy sup

18 plier and to make certain paymensuch ven
plier and to make certain paymensuch vendors. NONDISCRIMINATION NOTICE This institutionis prohibited from discriminating on the basis of race, color, national origin, disability, age, sex andin someasesreligion or political beliefs. The United StatesDepartment of Agrure (USDA) also rohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs or reprisalor retaliation for prior cil rights activity in any program or activity conducted or funded by USDA.sons with disabiitieswhorequire alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contt the gency (State or local) where they applied for benefits. Individualare deaf, hard f hearingor have speech disabilities may contact USDA through the Federal Relay Service at (800) 8778339. Additionally, program information may be made avaable in languages other than English.To file a Supplemental Nutrition Asnce Program (SNA) complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD3027), found online at: http://www.ascr.usda.gov/complaint_filing_st.html, and at any USDA office, or write a letter addressed to USDA and pe in the letter ll oftheinformation requested in the form.To request a copy of the complaint form, call (866) 6329992. Submit your completed form or letterto USDA by: (1)ail: U.S. Department of AgricultureOffice of the Assistant Secretary for Rights1400 Indpendence Avenue, SW Washington, D.C. 202509410(2)ax: (202) 6907442; or (3) mail: program.intake@usda.gov. ��PAGE LDSSatewide(Rev. /20For any other information dealing with Supplental Nutrition Assistance Program (SNAP) issues, persons should either conthe USDA SNAP Holine Number at (800) 2215689, which is alsoin Spanish, orcall the State Information/Hotline Numbers (click the link for a listing of hotline numbers by Sta); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htmfile a complainof discrimination regarding a program receiving ederal financial assistance through the U.S. Department of Health and Human Services (HHS), write HHS DirectOffice for Civil Rights, Room 515F, 200 Independence Avenue, S.W., Washn, D.C. 20201call(202) 6190403 (voice) or (800) 53797 (TTY). This institution is an equal opportunity provider.New York State additially prohibits discrimination based on gender identity, transgender statusder dysphoria, sexual orientation, marital status, military status, domesticviolence victim status, pregnancyrelated conditions, predisposing genetic characteristics, prior rest or conviction record, familial status, and retaliation for opposing uul discriminatorypractices. CONSENT FOR INVESTIGATION agreeto any nvestigationverify or confirm the information I have given in connection with my request for ic Assistance (PA), MedicaidSupplemental Nutrition Assistance Program (SBenefits, Home Energy Assistance ProgramBenefitsServices or Child Care Assistance.If additional information is requested, I will provide it. I will also cooperate fully witate and ederal personnel in any and/or SNAPQuality Co

19 ntrol Review.I am applying forSNAP, I un
ntrol Review.I am applying forSNAP, I understand that thesocial servicesdistrict will request and use information available through the Income and EligibilityVerificationSystem to invtigate my application, and may verify this information through collateral cts if discrepancies are found. I also understand that such information may affect my eligibility for SNAP and/or the level of SNAP enefits I receive. CONSENT FOR RELEASE CONFIDENTIAL UNEMPLOYMENT INSURANCE INFORMATIONI authorize the New Yorte Department of Labor(DOL) to release any onfidential information maintained by DOL for Unemployment Insurance (UI) purposes to the New York State Office of Temporary and Dability Assistance (OTDA). This information includes UI benefit claims andrecords. I understandthat OTDA, along with tate and local agency employees working in social services district offices, will use the UI information for establishing or veriing eligibility for, and the amount of, Public ssistanceMedicaidSupplal Nutrition Assistance Program enefits, Home Energy Assistance Program Benefits or Child Care Assistance,applied for in this application and for investigations to determinehether I received benefits to which I was not entitled.TDA mayalso sharinformation withthe New York State Office of Childrenand Family Services (OCFS) and the New York State Department of Health (DOH). OCFS will use the information to monitor Child Care Assistance program. RELEASE OF INFORMATION TO SERVICE PROVI give permission to the social services district and New York State to share information regarding PublicAssistance or Supplemental Nutrition Assistance Program benefits at I or any member of my householdfor whom I can legally give authorizative received, for purposes of verifying my eligibility for services and payment related to program administration provided by a State or local contractor. Such services may ilude, but are not limited tojob placement or training services provided lp me or members of myhouseholdobtain and retain employment CHANGE REPORTING I agree to inform the agencypromptlyof any change in my address, needs, income, and propty, ablebodied adult without dependents (ABAWD) status, pregnancy status ving arrangementsto the best of my knowledge or belieI am applying for hild are ssistance, I agree to inform the agency immediatelyof any change in family income,ho lives in my home, employment, child care arrangements or other changes may affect my continued eligibility or amount of my benefit. PENALTIES Federal and tate laws provide for penalties of fine, imprisonment or both if you donot tell the uth when you apply for Public Assistance, MedicaidSupplemental Nutritionstance Programervices or Child Care Assistance (Assistance, Benefits or Services) or at any time when you are questioned about your eligibility, or cause someone else noto tell the truth regarding your application or your continuing eligibilityalties also applyif you conceal or fail to disclose facts regarding your initial and continuing eligibility for Assistance, Benefits or Services, or if you conceal or fail toisclose facts that would affect the right of someone for whom you have a

20 ppto obtain or continue to receive Assis
ppto obtain or continue to receive Assistance, Benefits or Services. If you are an uthorized epresentative, such Assistance, Benefits or Services must be used for the other peon and not for yourself. Federal and tate laws provide that any transfer sets for less than fair market value made by an individual oran individual’s spouse, within months prior to the first of the month in which the individual is ��LDSSStatewide(Rev. /20PAGE both in receiof nursing facility services and has submitted an application for Medicaiy render the individual ineligible for nursing facilityservices or home andcommunitybased waivered services for a period of time. It is unlawful to obtain Assistance, Benefs or Services by concealing information or providing false information. LEMENTAL NUTRITION ASSISTANCE PROGRAM DISQUALIFICATION PENALTIES Any information you provide in connection with your application for the Supplemental NutritionAssistance Prram (SNAP) will be subject to verification by federal, state and local offs. If any information is incorrect, you may be denied SNAP Benefits. You maysubject to criminal prosecution if you knowingly provide incorrect information which affects elibility or the amount of benefits. Any person convicted of a felony for kgly using, transferring, acquiring, altering or possessing SNAP authorization cards or access devices may be fined up to $250,000, imprisoned up to 20 years or both. The indidual may also be subject to prosecution under the applicable federal and slaws. Anyone whois violating a condition ofprobationor parole, or anyonewho is fleeing to avoid prosecution, custody or confinement of a felonyand is actively being pursd by law enforcement, is not eligible to receive SNAP Benefits.You may bineligible forSNAPor foundto have committedan tentional Program Violation (IPVif you make a false or misleading statement, or misrepresent, conceal orwithhold factn order to qualify for benefits or receive more benefits; purchase a prowith SNAP benefits with the intent of obtaining cash byintentionally discarding the product and returning the container for the deposit amountor commit or attempt to commitny act that constitutes a violation of ederal or tate law for the purposusing, presenting, transferring, acquiring, eceiving, possessing or trafficking SNAP enefits, authorization cards or reusable documents used as part of the Electronic BenefiTransfer (EBT) system.Additionallythe following is not allowed andyoube disqualified from receiving SNAP enefits and/or be subject to penalties for actions that include:Using SNAP enefits to buy nonfood items, such as alcohol or cigarettesUsing SNAP benefits to pay for food previously purchased on credit; Allowomeone else to use your EBT card in exchange for cash, firearms, ammunition or explosives, ordrugs, or to purchase food for individuals who are notmembers of SNAP house; orUsing or having in your possession EBT cards that do not belong to without the card owner’s consent.Individuals found tohave committed an IPV either through an administrative disqualification hearing or by a federal, State orlocal court, have signed either a waive

21 r of right to an administrative disquali
r of right to an administrative disqualificatioring or a disqualification consent agreement in cases referred for prosecution shall be ineligible to participate in SNAPfor a period of: 12 monthsfor the firsSNAPIPV; months for the secondSNAPIPV; 24 months for the firstSNAPIPV that is on a court finding that the individual used or received SNAPenefits in a transaction involving the sale of a controlled substance llegal drugs or certain drugs for which doctor’s prescription is required); or 120 months if the individual is fouhave made a fraudulenstatement about whowhere livein order to get multiple SNAP enefits simultaneously, unlespermanently disqualified for a thirdIPV.Additionally, a court may bar an individual from partiing in SNAP for an additional 18 months.An individual can bermanendisqualififrom receiving SNAP Benefits for: firstSNAPIPV based on a court finding that the individual or receivSNAP enefits in a transaction involving the salfirearms, ammunition or explosives firstSNAPIPV based on a courtconviction for trafficking SNAP enefits for a combined amount of $500 or more (rafficking includes the illegal ustransfer, acquisition, alteration or possession of SNAP authoion cards or access devices) secondSNAPIPV based on acourt finding that theindividual used or received SNAP enefits in a transaction involving the le of a controlled substancllegal drugs or certain drugs for which a doctor’s prescripts required); or irdSNAP IPV REQUIREMENT TO REPORT/VERIFY HOUSEHOLD EXPENSESYour household must report child care and utility expensesin order toget a Supplemental NutritiAssistance Program (SNAPdeduction for these expenses. Your hold must report and verify rent/mortgage payments, property taxes, insurance, medical expenses and child support paid to household member in order to getSNAP deduction for thesexpenses.Failure to report/verify the above expenses will be as a statement byyourhousehold that you do not want to receive a deduction for thse unreported/unverified expenses. A deduction for these expenses may make you eligible for SNAPor mayncrease your SNAPenefits. You may report/verify these expensany time in the future. Thdeduction would then be applied to the calculation of SNAP enefits in future monthsin accordance with the rules for change reporting(see Change Reporting,bove) ��PAGE LDSSatewide(Rev. /20SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAMAUTHORIZEDESENTATIVE You can authorize someone who knows your household circumstances to apply for Supplemental Nutrition Assistance Program (SNAP)enefitsfor you. u can also authorize someonoutside your household to get SNAP Benefits for you or to use to buy food for you. If you would like to authorize someone,you must do so in writing.You may authorize someone by printing the person’s name, address, and phone number immediately beland having them sign in the signature section at the end of application.Whenan Authorized Representative is applying onbehalf ofa SNAP householdthat does not reside in an institution, both the AuthorizedRepresentative and a responsible adultember of the household must sign and date the signature sectiothe

22 end of this application, unless the SNAP
end of this application, unless the SNAP household has otherwise designated the Authorized Representative to do so in writing. NAME, ADDRESS AND PHONE NUMBER OF AUTHORIZED REPRESENTATI(PLEASE PRINT): STANDARD UTILITY ALLOWANCE I unded that Public Assistance and Supplemental Nutrition Assistance Program (SNAP)recipientsare categorically income eligible for the Home EnergyAssistance Program (HEAP). lso understandhat if I have not received a HEAP benefit of greater than $20 e current month or previous 12 months, or a similar energy assistance benefit, I must pay for heating or air conditioning separately from my rent inorder to receive the heating/cooling sndard utility allowance (i.e., a deduction) for SNAP.I underthat the State will use my Social Security Number to verify with my home energy vendorsthe receipt of HEAP. This authorization also includes permission for anof my home energy vendorsincluding my utility) to release certain statistical informatincluding but not limited to, my annual electricity usage, electricity cost, fuel consumption, fuel type, annual fuel cost and payment history to theNew York State Office ofTemporary andisability Assistance, the local ocial ervices istrict and tited States Departmentof Health and Human Services for the purposes ofLow Income Home Energy Assistance Program performance measurement. RELEASE OF MEDICAL INFORMATIONI consent tthe release of any medical information about me and any membermy family for whom I can give consent by my rimary are rovider, any other health careprovider or the New York State Department of Health (DOH) to my health plan and any health care priders involved in caring for me or my family, as reasonably nery for my health plan or my providers to carry out treatment,payment, or health care operations; by my health plan and any health care providers toDOH and other authorizedfederal, statand local agencies for purposes of administration of Medicaid, by my health plan toother persons or organizations, as reasonably necessary for my alth plan to carry out treatment, payment, or health care operations. authorize therelease of anhealthrelated information about me and any members of my famir whom I can legally give authorizationrelated to the provision of assistance and services and my ability to participate in work activities, including employment, to the New York State Oice of Temporary and Disability Assistance (OTDA), the New Yorte Office of Children and Family Services or the local socialservices districtas reasonably necessary for the provision of PublicAssistance benefitsfor servicesincluding child welre servicesfor determining appropriate work activity assignmfor determining the need to apply and for making applicationfor Supplemental Security Income Benefitsfor establishing appropriate treatment plans for restoring employabilityand for termining eligibility for exemptions from the State sixtymonte limit on cash assistancereceipt. If I am required to applyfor benefits administered by the Social Security Administration, the information specified above may be shared with the SociaSecurity Administration.I also agree that the information r

23 ed may include HIV, mental health or alc
ed may include HIV, mental health or alcohol and substance abuse information about me andmembers of my family, to the extent permitted by law, unless a box is checked belowIf more than e adult in the family is joining a Medicaid health plan, the sure of each adultying is necessary for consent to release information.I understandthat my ability to consent to the release of information relating to any minor children for whom Iay give consent is limited by the extent to which I can obtainrmation regardingtreatment, diagnosis and procedures on their behalf._______ Do not disclose HIV/AIDS information ______ Do not disclose drug and alcohol informati_______ Do t disclose mental health information RELEASE OF INFORMATIONEALTH SERVICE PROVIDERI give permission to the social services district and the State of New York to share information with health service providers, as designated by the social servis district or the State of New York, regarding Public Assistannefits that I or any member of my household for whom I can legally giveauthorization have received or are eligible to receive, for the purpose of improving thequality of my healthcare aoverall wellbeing, and to facilitate receipt of additional bts for which I, or members of my household, may be eligible. ��LDSSStatewide(Rev. /20PAGE RELEASE OF EDUCATIONAL RECORDSI give permission to the New York State Department of Healthand the social services dirict to:1) obtain any information regarding the educational reof myself and/ormy minor child(ren), herein named, including information necessary forclaiming Medicaid reimbursement for healthrelated educational servicesand 2) provide the appropate federal government agency access to this information for tle purpose of audit. RELEASE OF INFORMATION FOR THE EARLY INTERVENTION PROGRAM y child is evaluated for or participates in the New York State Early Intervention Program, I give mission to the social servicesdistrict and New York State to my child’s Medicaidligibility information with my county or municipal Early Intervention Program for the purpose of billing Medicaid CHILD/TEEN HEALTH PROGRAM I understand that imy child is on Medicaid, can get comprehensive py and preventive care,includingall necessary treatment through the Child/Teen Health Program. I can get more information on this program from the social services district MEDICARE horize payments under “Medicare” (Part B of Title XVIII, Smentary Medical Insurance Program) to be made directly to physicians and medicalsuppliers on any future unpaid bills for medical and other health services furnished to me whileI am eligibleor Medicaid. REIMBURSEMENT OF MEDICAL EXPENSES MEDICYou have a rightas part of your Medicaidapplication, or within two years fromthe date ofyour application, to request reimbursement of expenses you paid for covered medical care, servicesnd supplies received during the threemonth period prior tmonth of your application. After the date of your application, reimbursement ofcovered medical care, services and supplies will only be available if obtained fromMedicaidolled provider ASSIGNMENT OF INSURANCE/OTHER

24 BENEFITS AND DIRECT PAYFor PublicAssist
BENEFITS AND DIRECT PAYFor PublicAssistance and Medicaid, I agree to file any claims for health or accident insurance benefitsand to pursue anypersonal injury claimsor any other resources to which I may be eitled, and do hereby assign any such resources to the socirvices districto whom this application is made. In addition, I willassist inmaking any assigned benefits available to the social services district to whom thisapplication is made.I auorize payments owed to me or members of my household for hor accident insurancebenefits to be made directly to the appropriatesocial services district for medical and other health services furnished while we are eligible for Medicai MEDICAIDECOVERIES Upon receipt of Medicaid, a lien may be filed recovery may be made against your real property under certain circumstances if you are in amedical institution and not expected to return home. MApaid on your behalf may be recovered from rsons who had legal responsibility for your support at themedical serviceswereobtained. MA may also recover the costof services and premiums incorrectly paidI understand that effective April 1, 2014,if I get Medicaid through New York State oHealth:No lien will be placed on my real property prior tdeath.Recovery from assets in my estate upon my death is limited to the amount Medicaid paid for the cost of nursing home care, home and communitybased services, and related ospital and prcription drug services received on or after my 55th birthd PUBLICASSISTANCE RECOVERIES Public Assistance (PA)you receive for yourselfand for persons for whom you are legally responsible to support is recoverable fromproperty or money you posss or may acquire. You may be required, as a condition of ring PA, to execute a deed or mortgage of real property you own. Your tax refunds and portions of lottery winnings may be taken to repay your debt for PA.AUTHORIZATION TO REPAY PUBLIC ASSTANCE BENEFITS FROM RETROACTIVE SUPPLEMENTAL SECURITY INCOI authorize the Commissioner of the Social Security Administration (SSA) to use my first payment of Supplemental ecurity ncomeSSI); i.e. my retroactive SSI payment) to reimburse the localocial ervices istrict (SSD) for ��PAGE LDSSatewide(Rev. /20Public Assistance (PA) tD pays me from ate or local funds while SSA decides if I ameligiblefor SSI. SSA will not reimburse the SSD for PA that was paid using any federal funds. I will be bound bthis authorition only if the State gives notice to SSA that I andpresentative havesigned it. The State must give notice within 30 calendar daysof matchingmy SSI record with my tate record. SSA will not acceptit after 30 calendar days. Instead, SSA wl send me my retroactive SSI payment under SSA rules. Onlfirst payment of SSI can be used. If my first payment is larger than the amountowed to theSSD, SSA will send the rest to me under its rules. A can reimburse the SSD in two situations: 1) It will repay the SSD if I apply for SSI and SSA finds igible2) ill repay the SSD if my SSI benefits are reinstated after termination or suspension.SSA will only reimburse the SSD for PA it me during the time I am waiting for an SSdetermination of el

25 igibility. This is called “interim
igibility. This is called “interim ass” The period begins1) with the first month I become eligible for payment ofSSI benefits; or 2) on the first day I am reinstated after my SSI was suspended or terminated. The period incles the month SSI payments actually begin.If the SSD cannop my last PA paymthe period ends the next month.No later than 10 days after SSA reimburses the SSD, the SSD must send me a notice telling methe amount of interim assistance paid. Theotice will also tell me that SSA will send me a letter telme how any remaining SSI money owed to me will be sent by SSAandthatif I do not agree with a state decision, how I can appeal the decision to the state. Underits rules, SSA may use theate I sign this authorization as the date I first become ele for SSI. It wo this only if I apply for SSI within the next 60 days.his authorization applies to any SSI application or appeal I now have pending beforeSSA. This authorization teinates if my SSI case is completely decided. It terminaten SSA first pays me. tateand I can also agree to terminate the authorization. I must sign a new authorization consistent with NYSrules if I reapply for SSI after this authorization ternates, or if I file a new SSI claim while I have an SSI aption or appeal pendingI will be given an opportunity for a fair hearing if Idisagree with a decision the SSD made about reimbursement. I received a copy of the pamphlet called “What Yohould Know About Social Services Programs.” I understand it says about interim assistance. SUPPORTApplying for or receiving Family Assistance (FA), Safety Net Assistance (SNA) orTitle IVfoster care operates as an assignment to the State athe social services district of any rights to support froother person that theapplicant or recipient may have in own right or on behalf of any other family member for whom the applicant or recipient is applying for, or receivingassisnce (Social Services Law, Sections 158 and 348). Thiignment is limited in certain situations. Other sections of this application contain additional assignments. ASSIGNMENT OF SUPPORT RIGHTS I assign to the tateand social services district anyights I have to support from persons having legal reibility for my supportand any rights I have to support on behalf of any family member for whom I am applying for or receiving assistance. Where applying for or receiving Family Assistanceor SafeNet Assistancemy assignment of support rights is ed to support which accrues during the period that I and/or any family member receives assistance.However, any support rights that I assigned to the tate on behalf of myself or anyfamily memberrior to October 1, 2009, continue to be assigned to tate. HOME ENERGY ASSISTANCE PROGRAM I understand that by signing this application/certification, I consent to any investigation to verify or confirm the information I have givenand other invtigation by any authorized government agency in connn with Home Energy Assistance Program (HEAP) benefits.I also consent to allow the information provided on this application to be used in referralsto available weatherization assistance programs d my utility company’s

26 low income programs.I underthat the Sta
low income programs.I underthat the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any ofhome energy vendors (includinmy utility) to release certain statistical informatincluding but not limited to, my annual electricity usage, electricity cost, fuel consumption, fueltype, annual fuel cost and payment history to theNew York State Office of Temporaryand DisabilitAssistance, the local ocial ervices istrict and tited States Departmentof Health and Human Services for the purposes of Low Income Home Energy Assistance Program performance measurement.SEXUALASSALT INFORMATION If you are avictim of sexl assault, you have the right to request referral intion from the social services district. If you request referral information, thesocial services district must provide you with the addresses and phone numbers of any: 1) local hospitals offering xual assault forensic examiner services certified by ��LDSSStatewide(Rev. /20PAGE NYS Department ofHealth; 2) local rape crisis centers; and 3) local advocacy, counseling, and hotline services appropriate for victims of sexual assault. In addition, the social services districtust provide you with the NYS Hotline for Sexual Assand Domestic Violence numbers: (800) 9426906 and (800) 81856 (TTY). CERTIFICATION FORCHILD CARE ASSISTANCE If I am applying for Child Care Assistance, I certify that my family resources doot exceed $1,000,000. ONLY COMPLETE THE FOLLOWIIF YOU WANT TO WITHDRAW YOUR APPLICATION FOR ONE ORPROGRAMS. I Consento WithdrawMy Application For: 偵bli挠As獩獴an捥
PA) † 䍨ild⁃a牥 楮楥uf⁐A†† Supplemental⁎utrition⁁ssistan捥⁐rogra洠⡓NA Medi捡id⁡nd⁓乁P caid⁡nd PA†† S敲癩捥猬⁩n捬uding⁆o獴敲⁃慲e 䍨ild⁃a牥⁁ssist慮ce Em敲g敮c礠A獳i獴慮c攠Only I⁵nder獴慮d⁴h慴⁉慹⁲e慰pl礠慴⁡n礠ti浥䅐PLI䍁乔/䅕T䡏剉娀E䐠REP剅SE乔䅔IVESIG乁TU剅AT䔠卉GN䕄 I have read and understand t h e notices above. I under stand and agree to the assignments, aut horizations and cons ents above . I swe ar and/or affirm under the penalties of perjury th at the information I have given or will give to tsocial services districtis complete and correct. A P P L I CANT SIGNATURE x DATE SIGNED SPOUSE OR PROTECTIVE REPRESENTA TIVE SIGNATURE x D ATE SIGNED AUTHO RIZED REPRESENTATIVE SIGNATURE x DATE SIGNED “If you are not registered to vote where you live now, would you like to apply to register here today?” YES because I choose not to register OR I am already registered at my current address OR I asked for and received a mail registration form If you checked YES, mlease commlee he VOTER REGISTRATION APPLICATION belowIf you do not check any box, you will be considered to have decided not to register to vote at this time. Important!Applying to register or declining to register to vote will not affect theamount of assistance that you will be provided by this agency.If you would like helm �lling

27 ou he voer regisraion am
ou he voer regisraion ammlicaion form, we will help you. The decision whether to seek or accept help is yours. Signature Date Please Print Name Are you a U.S. citizen?you answered , do no commlee his form Will you be 18 years old on or before election dayB) Are you at least 16 years of age and understand that you must be 18 ears of age on or before election day to vote, and that until you will be eighteen years of age at the time of such election your registration will be marked “pending” and you will be unable to cast a ballot in any election? you answered NO o boh of he mrior nuesions, you canno regiser o voe YES NO For Board Use Only Last NameFirst Name Middle Iniial uf�u ddress where you live (do no give P.O. bou) m. No. Ciy,Town,Village Zim Code Couny ddress where you ge your mail (if differen han above) P.O. Bou, Sar Roue, ec. Pos Of�ce Zim Code Dae of Birh Gender (omional) Telemhone (omional) Email (omional) The las year you voed our address was (give house number, sree and ciy)In couny,sae Under he name (if differen from your name now) ID Number f�davi: I swear or af�rm ha • m a citizen of the United States. will have lived in he couny, ciy or village for a leas 30 days before the election. • ill meet all requirements to register to vote in New York State. • his is my signature or mark on the line below. he above informaion is rue, I undersand ha if i is no rue, I can be conviced and �ned um o $5,000 and,or jailed for um o four years. Signature or Mark in ink DateNYS Agency-Based Voter Registration Form VOTER REGISTRATION APPLICATION(insrucions on back) Last Name(Optional) Register to donate your organs and tissues First Name Address Birh DaeMiddle InitialSuf�u Ciy,Town,Village Apt NumberZim CodeBy signing below, you cerify ha you are: • 6 years of age or older onsen o donae all of your organs and issues for ransmlanaion, research, or boh; uhorizing he Board of Elecions o mrovide your name and idenifying informaion o NS Donae Iife Regisry for enrollmen; nd auhorizing he Regisry o allow access o his informaion o federally regulaed organ procurement organizations and NYS-licensed tissue and eye banks and others Signature Date 1 34561011 M Ft. In. Democratic partyRemublican maryConservaive maryWorking Families partyGreen mary Libertarian partyIndependence partySAM party

28 Other Political Party I wish to enroll i
Other Political Party I wish to enroll in a political party I do not wish to enroll in any political party and wish to be an independent voterNo party EmailDMV or ID NC Number YES NO YES NO Qualifications for Registration You Can Use This Form To: • register to vote in New York State; • change your name and/or address, if there is a change since you last voted; • enroll in a political party or change your enrollment; • pre-register to vote if you are 16 or 17 years of age. To Register You Must: • be a U.S. citizen; • be 18 years old (you may pre-register at 16 or 17 but cannot vote until you are 18); • be a resident of the County, or of the City of New York at least 30 days before an election; • not be in prison or on parole for a felony conviction (unless parole pardoned or restored rights of citizenship); • not claim the right to vote elsewhere; and • not found to be incompetent by a court. Important! If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: NYS Board of Elections 40 North Pearl St, Suite 5 Albany, NY 12207-2729 Telephone: 1-800-469-6872; TDD/TTY users contact the New York State Relay at 711; or visit our web site - www.elections.ny.gov Your decision to register will remain confidential and will be used only for voter registration purposes. Anyone not choosing to register to vote and/ or information regarding the office to which the application was submitted will remain confidential, to be used only for voter registration purposes. Verifying your identity We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID number), or the last four digits of your social security number, which you will fill in Box 9. If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement, paycheck, government check or some other government document that shows your name and address. You may include a copy of one of those types of ID with this form. If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time. To complete this form: It is a crime to procure a false registration or to furnish false information to the Board of Elections. Box 9: You must make one selection. For questions refer to Verifying your identity above. Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?). If you voted before under a different name, put down that name. If not, write “Same”. Box 11: Check one box only. Political party enrollment is optional but that, in order to vote in a primary election of a political party, a voter must enroll in that political party, unless state party rules allow otherw