NEW YORK STATE APPLICATION FOR CERTAIN BENEFITS … · NEW YORK STATE APPLICATION FOR CERTAIN...

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LDSS-2921 LP Statewide (Rev. 7/16)

This information is being provided in this alternate formatfor informational purposes only. In order to apply, you mustsubmit an application in written, non-alternative format.

NEW YORK STATE APPLICATIONFOR CERTAIN BENEFITS ANDSERVICES

If you are blind or seriously visually impaired and need thisapplication in an alternative format, you may request onefrom your social services district. For additionalinformation regarding the types of formats available andhow you can request an application in an alternativeformat, see the instruction book (PUB-1301 Statewide),available at www.otda.ny.gov orhttps://www.health.ny.gov/.

If you are blind or seriously visually impaired, would youlike to receive written notices in an alternative format?

☐ Yes

☐ No

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If yes, check the type of format you would like:

☐ Large Print;

☐ Data CD;

☐ Audio CD;

☐ Braille, if you assert that none of the other alternativeformats will be equally effective for you.

If you require another accommodation, please contactyour social services district.

We are committed to assisting and supporting you in aprofessional and respectful manner. You are responsiblefor participating in activities, including work activities forPublic Assistance and the Supplemental NutritionAssistance Program, where required, so you can becomeself-sufficient. Whenever you see "Public Assistance" or"PA" on the application, it means "Family Assistance" and/or "Safety Net Assistance." We call both programs "PublicAssistance." These PA programs are meant to assist youonly until you can fully support yourself and your family.Please refer to the instruction book (PUB-1301Statewide) and "What You Should Know" Books 1, 2and 3 (LDSS-4148A, LDSS-4148B, and LDSS-4148C)when completing this application, and contact yoursocial services district with any questions.

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When you see "MA" on the application, it means"Medicaid." You may apply for MA using this applicationonly if you are also applying for Public Assistance or theSupplemental Nutrition Assistance Program at the sametime. If you wish to only apply for MA, you can go online athttps://nystateofhealth.ny.gov/ and/or call 1-855-355-5777for more information or to apply, or you may use the MA-only paper application—Form DOH-4220, which yourworker can give you, or call MA help line at1-800-541-2831. If you want to apply only for the MedicareSavings Program (MSP), you must apply with FormDOH-4328, which your worker can provide to you. If youhave an immediate need for personal care services, youshould apply for MA separately using the DOH-4220 MAapplication form.

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SECTION 1 CHECK EACH PROGRAM YOUOR ANY HOUSEHOLD MEMBER AREAPPLYING FOR

☐ Public Assistance (PA)

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☐ Child Care in lieu of PA

☐ Supplemental Nutrition Assistance Program (SNAP)

☐ Medicaid (MA) and SNAP

☐ Medicaid (MA) and PA

☐ Services (S), including Foster Care (FC)

☐ Child Care Assistance (CC)

☐ Emergency Assistance Only (EMRG)

SECTION 2

WHAT IS YOUR PRIMARY LANGUAGE?

☐ ENGLISH

☐ SPANISH

☐ OTHER (specify) ____DO YOU WANT TO RECEIVE NOTICES IN:

☐ ENGLISH ONLY

☐ ENGLISH AND SPANISH

SECTION 3 APPLICANT INFORMATION

PLEASE PRINT CLEARLY

FIRST NAME ____M.I. ____LAST NAME ____MARITAL STATUS ____

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PHONE NUMBER WITH AREA CODE ____STREET ADDRESS ____

APT. NO. ____CITY ____COUNTY ____STATE ____ZIP CODE ____

IN CARE OF NAME (COMPLETE IF YOU RECEIVEYOUR MAIL IN CARE OF ANOTHER PERSON) ____MAILING ADDRESS (IF DIFFERENT FROM ABOVE)____


HOW LONG HAVE YOU LIVED AT YOUR PRESENTADDRESS?

YEARS ____MONTHS ____IS THIS A SHELTER?

☐ YES

☐ NOANOTHER PHONE WHERE YOU CAN BE REACHED

NAME ____PHONE NUMBER WITH AREA CODE ____

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DIRECTIONS TO CURRENT ADDRESS ____FORMER ADDRESS ____


IF YOU ARE CURRENTLY WITHOUT A HOME, CHECKHERE☐AGENCY HELPING APPLICANT/CONTACT PERSON____PHONE NUMBER WITH AREA CODE ____DO YOU NEED THE MEDICAID PORTION OF THISAPPLICATION AND THE POTENTIAL RECEIPT OF ANYMEDICAID COVERAGE TO BE KEPT CONFIDENTIAL?

☐ YES

☐ NO

SECTION 4—If You Are Applying For SNAP:

You can file an application the day you get it. In order tofile a SNAP application, it must have, at minimum, yourname, address (if you have one) and signature below. Youmust complete the application process, including signingthe last page of the application and being interviewed. Ifeligible, you will get SNAP benefits back to the date you

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filed the application. You must be told, within 30 days ofthe date you turned in (filed) your application for SNAPbenefits, if your application is approved or denied. If yourhousehold has little or no income or liquid resources, or ifyour rent and utility expenses are more than your incomeand liquid resources, you may be eligible to get SNAPbenefits within five calendar days of the date you file. Ifyou are a resident of an institution and are applying forboth Supplemental Security Income (SSI) and SNAPbenefits prior to leaving the institution, the filing date of theapplication is the date you leave the institution.

SNAP APPLICANT/REPRESENTATIVE SIGNATURE____DATE SIGNED ____

SECTION 5 DO ANY OF THESE APPLY TOYOU?

1☐ Pregnant2☐ Victim of Domestic Violence3☐ Need To Establish Paternity4☐ Need Child Support5☐ Drug/Alcohol Problem6☐ Fuel Or Utility Shutoff7☐ No Place To Stay/Homeless

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8☐ Fire Or Other Disaster9☐ Have No Income10☐ Serious Medical Problem11☐ Pending Eviction12☐ No Food13☐ Need Foster Care14☐ Need Child Care15☐ Problems with English16☐ Reasonable Accommodations17☐ Other ____

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SECTION 6—HOUSEHOLDINFORMATION—List everybody who lives withyou, even if they are not applying with you. Listyourself on the first line.

LN 01FIRST NAME ____M.I. (Middle Initial) ____LAST NAME ____THIS PERSON IS APPLYING FOR:

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PA☐SNAP☐MA☐CC☐FC☐S☐EMRG☐

DATE OF BIRTHMonth ____Day ____Year ____

SEX M OR F ____RELATIONSHIP TO YOU SELFSOCIAL SECURITY NUMBER OF APPLYINGHOUSEHOLD MEMBERS (See instruction book,PUB-1301 Statewide, or talk to your social servicesdistrict) ____HIGHEST SCHOOL GRADE COMPLETED ____DOES THIS PERSON (INCLUDING MINORCHILDREN) BUY FOOD OR PREPARE MEALS WITHYOU?

YES☐NO☐

LN 02FIRST NAME ____M.I. (Middle Initial) ____

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LAST NAME ____THIS PERSON IS APPLYING FOR:



SEX M OR F ____RELATIONSHIP TO YOU ____SOCIAL SECURITY NUMBER OF APPLYINGHOUSEHOLD MEMBERS (See instruction book,PUB-1301 Statewide, or talk to your social servicesdistrict) ____HIGHEST SCHOOL GRADE COMPLETED ____DOES THIS PERSON (INCLUDING MINORCHILDREN) BUY FOOD OR PREPARE MEALS WITHYOU?

YES☐NO☐

LN 03

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FIRST NAME ____M.I. (Middle Initial) ____LAST NAME ____THIS PERSON IS APPLYING FOR:




YES☐

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NO☐LN 04

FIRST NAME ____M.I. (Middle Initial) ____LAST NAME ____THIS PERSON IS APPLYING FOR:



SEX M OR F ____RELATIONSHIP TO YOU ____SOCIAL SECURITY NUMBER OF APPLYINGHOUSEHOLD MEMBERS (See instruction book,PUB-1301 Statewide, or talk to your social servicesdistrict) ____HIGHEST SCHOOL GRADE COMPLETED ____

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DOES THIS PERSON (INCLUDING MINORCHILDREN) BUY FOOD OR PREPARE MEALS WITHYOU?

YES☐NO☐




SEX M OR F ____RELATIONSHIP TO YOU ____SOCIAL SECURITY NUMBER OF APPLYINGHOUSEHOLD MEMBERS (See instruction book,

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PUB-1301 Statewide, or talk to your social servicesdistrict) ____HIGHEST SCHOOL GRADE COMPLETED ____DOES THIS PERSON (INCLUDING MINORCHILDREN) BUY FOOD OR PREPARE MEALS WITHYOU?

YES☐NO☐




SEX M OR F ____RELATIONSHIP TO YOU ____

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SOCIAL SECURITY NUMBER OF APPLYINGHOUSEHOLD MEMBERS (See instruction book,PUB-1301 Statewide, or talk to your social servicesdistrict) ____HIGHEST SCHOOL GRADE COMPLETED ____DOES THIS PERSON (INCLUDING MINORCHILDREN) BUY FOOD OR PREPARE MEALS WITHYOU?

YES☐NO☐




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YES☐NO☐



DATE OF BIRTHMonth ____

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Day ____Year ____


YES☐NO☐

PLEASE LIST MAIDEN OR OTHER NAMES BY WHICHYOU OR ANYONE IN YOUR HOUSEHOLD HAVE BEENKNOWN

Line No.ONCFIRST NAME ____M.I. ____LAST NAME ____

Line No.ONC

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FIRST NAME ____M.I. ____LAST NAME ____

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SECTION 7—RACE/ETHNICITY—

Providing this information is voluntary. It will not affect theeligibility of the persons applying or the level of benefitsreceived. The reason for requesting this information is toensure that program benefits are distributed withoutregard to race, color, or national origin.

H HISPANIC OR LATINOI NATIVE AMERICAN OR ALASKAN NATIVEA ASIANB BLACK OR AFRICAN AMERICANP NATIVE HAWAIIAN OR PACIFIC ISLANDERW WHITEU UNKNOWN (MA ONLY)

ENTER Y (YES) OR N (NO) FOR HISPANIC OR LATINO

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ENTER Y (YES) OR N (NO) FOR EACH RACE)

LN 01H ____I ____A ____B ____P ____W ____U ____

LN 02H ____I ____A ____B ____P ____W ____U ____

LN 03H ____I ____A ____B ____P ____W ____U ____

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LN 04H ____I ____A ____B ____P ____W ____U ____

LN 05H ____I ____A ____B ____P ____W ____U ____

LN 06H ____I ____A ____B ____P ____W ____U ____

LN 07H ____

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I ____A ____B ____P ____W ____U ____

LN 08H ____I ____A ____B ____P ____W ____U ____

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Please read this entire page carefully beforecompleting it. If you have questions, see theinstruction book (PUB-1301 Statewide) or talk to yoursocial services district.

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SECTION 8—CITIZENSHIP/NON-CITIZENWITH SATISFACTORY IMMIGRATIONSTATUS

LIST EVERYONE WHO IS APPLYING OR WHO ISREQUIRED TO APPLY.

You have to fill out Sections 8 and 9 if you are:

• Applying for Child Care Assistance only, but you needto fill out the information only for the children who wouldbe receiving Child Care Services.

• Applying for Foster Care only, but you need to fill outthe information only for the children who would bereceiving Foster Care.

• Applying for other Services under certaincircumstances.

SECTION 9—CERTIFICATION

Some social services programs require that you certifythat you are a United States citizen, Native American ornational of the U.S., or a non-citizen with satisfactoryimmigration status. Other programs do not.

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You MUST sign the Certification below only if you are aUnited States citizen, Native American or national of theUnited States, or a non-citizen with satisfactoryimmigration status, and you are applying for:

• Public Assistance (where there are children in thehousehold or a member of the household is pregnant),or

• The Supplemental Nutrition Assistance Program, or• Medicaid (except if the applicant is pregnant), or• Child Care Assistance (certification is needed for the

children only), or• Foster Care (certification is needed for the children

only), or• Other Services under certain circumstances;• Emergency Payment Assistance

An adult household member or authorized representativemay sign for all household members. Example: A parentwithout a satisfactory non-citizen status may sign for his/her child with a satisfactory non-citizen status.

An application for SNAP must list all persons living in theSNAP household. An application for PA must list allchildren for whom you are applying, their brothers andsisters, and all parents of those children who live together.If you do not check whether a listed person is a United

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States citizen, national of the U.S. or an non-citizen with asatisfactory immigration status, or provide an U.S.Citizenship and Immigration Services (USCIS) number(Alien Registration Number) or a non-citizen number (ifapplicable), that person will not be given assistance andthe remaining members of the household will receivereduced benefits. If you are a Native American, checkcitizen/national.

LN 01FIRST NAME ____MI ____LAST NAME ____Check either "CITIZEN/NATIONAL" or "NON-CITIZEN"for each person.

☐ CITIZEN/NATIONAL

☐ NON-CITIZENUSCIS NUMBER (ALIEN REGISTRATION NUMBER)OR NON-CITIZEN NUMBER (If Applicable) A____



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LN 05FIRST NAME ____MI ____

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LAST NAME ____Check either "CITIZEN/NATIONAL" or "NON-CITIZEN"for each person.








☐ NON-CITIZEN

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USCIS NUMBER (ALIEN REGISTRATION NUMBER)OR NON-CITIZEN NUMBER (If Applicable) A____




SIGN * AND DATE THE BOX BELOW FOREACH APPLICANT.

In the case of an applying non-citizen with a satisfactoryimmigration status, check the program(s) for which eachapplying non-citizen has satisfactory immigration status.(See the instruction book, Pub-1301 Statewide.)

CERTIFICATIONSign Name ____DATE ____PA☐SNAP☐

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MA☐CC☐FC☐S☐EMRG☐

CERTIFICATIONSign Name ____DATE ____PA☐SNAP☐MA☐CC☐FC☐S☐EMRG☐


CERTIFICATION

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Sign Name ____DATE ____PA☐SNAP☐MA☐CC☐FC☐S☐EMRG☐


CERTIFICATIONSign Name ____DATE ____PA☐SNAP☐MA☐CC☐

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FC☐S☐EMRG☐



By checking a box above and by signing thecertification in Section 9, I hereby certify, under

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penalty of perjury, that I, and/or the person(s) forwhom I am signing, am a United States citizen, NativeAmerican or national of the United States, or a non-citizen with satisfactory immigration status.

I understand that signing this Certification may resultin information about applying members of myhousehold being submitted to the United StatesCitizenship and Immigration Services for verificationof non-citizen status, if applicable.

The use or disclosure of the information above isrestricted to persons and organizations directlyconnected with the verification of citizenship status,and the administration or enforcement of theprovisions of the Public Assistance, SupplementalNutrition Assistance, Medicaid, Child Care Assistance,Foster Care and Services Programs.

* A person who wishes to sign the Certification butcannot write may make an "X" on the line in front of awitness. The witness must sign below.

I witnessed the marks made in lines: ____Signature of witness: ____Date Signed: ____

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SECTION 10—INFORMATION REGARDINGREFERRAL TO THE CHILD SUPPORTENFORCEMENT UNIT

If you are applying only for child care assistance, you arenot required to pursue child support and do not have to fillout this section. If you are applying for Medicaid in additionto Public Assistance or the Supplemental NutritionAssistance Program, you may have to help us obtainmedical support for yourself and your applying children.Answer the following questions to determine if you need tocomplete this section. Include yourself, as appropriate:

1. Are you applying for an individual under the age of 21who was born out of wedlock and for whom paternity(legal fatherhood) has not been established?

☐ Yes

☐ No2. Are you applying for an individual under the age of 21who has an absent father or mother (noncustodialparent)?

☐ Yes

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☐ No

You do not need to complete this section if youanswered "No" to both of these questions. Go toSection 11.

You must complete this section if you answered "Yes"to either or both of these questions. Provide the namesof all individuals under the age of 21 for whom you areapplying and any information you currently have aboutthose individuals' noncustodial parents or putative(alleged) fathers.

3. Are you under the age of 21?

☐ Yes

☐ No

If you answered "Yes" to this question, provide theinformation for your noncustodial parent(s) or putativefather(s).

As a condition of obtaining assistance, you are required toassign certain rights related to support, as described in theNotices, Assignments, Authorizations, and Consentssection at the end of this application. You will be providedwith the LDSS-4882 form, "Information About ChildSupport Services and Application/Referral for Child

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Support Services," to complete and return to the ChildSupport Enforcement Unit. Except in situations ofdomestic violence or other good cause, as a condition ofobtaining assistance you are required to cooperate withthe Child Support Enforcement Unit to locate anynoncustodial parent or putative father; establish paternityfor each individual under the age of 21 born out ofwedlock; and establish, modify, and/or enforce orders ofsupport. You also will be provided with the LDSS-4279form, "Notice of Responsibilities and Rights for Support,"which explains your responsibilities and your rights if youdo not cooperate with the Child Support Enforcement Unit.

A. NAME OF INDIVIDUAL UNDER AGE 21 ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SNAME AND ADDRESS ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SDATE OF BIRTH

Month ____Day ____Year ____

NONCUSTODIAL PARENT OR PUTATIVE FATHER'SSOCIAL SECURITY NUMBER ____

B. NAME OF INDIVIDUAL UNDER AGE 21 ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SNAME AND ADDRESS ____

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NONCUSTODIAL PARENT OR PUTATIVE FATHER'SDATE OF BIRTH



C. NAME OF INDIVIDUAL UNDER AGE 21 ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SNAME AND ADDRESS ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SDATE OF BIRTH



D. NAME OF INDIVIDUAL UNDER AGE 21 ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SNAME AND ADDRESS ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SDATE OF BIRTH


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E. NAME OF INDIVIDUAL UNDER AGE 21 ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SNAME AND ADDRESS ____NONCUSTODIAL PARENT OR PUTATIVE FATHER'SDATE OF BIRTH



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SECTION 11—TAX FILING/DEPENDENTSTATUS—

Please select the tax status for each individual living in thehousehold.

FIRST NAME ____MIDDLE INITIAL ____LAST NAME ____

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TAX STATUSSINGLE☐MARRIED FILING JOINTLY☐MARRIED FILING SINGLE☐HEAD OF HOUSEHOLD (WITH QUALIFYINGINDIVIDUAL)☐QUALFIYING WIDOW(ER) WITH DEPENDENTCHILD☐DEPENDENT AND WILL BE FILING TAXES☐WILL NOT BE FILING TAXES☐



FIRST NAME ____MIDDLE INITIAL ____

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LAST NAME ____TAX STATUS

SINGLE☐MARRIED FILING JOINTLY☐MARRIED FILING SINGLE☐HEAD OF HOUSEHOLD (WITH QUALIFYINGINDIVIDUAL)☐QUALFIYING WIDOW(ER) WITH DEPENDENTCHILD☐DEPENDENT AND WILL BE FILING TAXES☐WILL NOT BE FILING TAXES☐



FIRST NAME ____

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MIDDLE INITIAL ____LAST NAME ____




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TAX STATUSSINGLE☐MARRIED FILING JOINTLY☐MARRIED FILING SINGLE☐HEAD OF HOUSEHOLD (WITH QUALIFYINGINDIVIDUAL)☐QUALFIYING WIDOW(ER) WITH DEPENDENTCHILD☐DEPENDENT AND WILL BE FILING TAXES☐

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WILL NOT BE FILING TAXES☐

Tax dependents not living in the household. Please listany tax dependents who do not live with you and areclaimed by you or anyone in your household. If you do notfile taxes, you can skip this question.

NAME OF TAX DEPENDENTFIRST NAME ____MIDDLE INITIAL ____LAST NAME ____

NAME OF TAX FILERFIRST NAME ____MIDDLE INITIAL ____LAST NAME ____



NAME OF TAX DEPENDENTFIRST NAME ____

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MIDDLE INITIAL ____LAST NAME ____




SECTION 12—ABSENT/DECEASED SPOUSEINFORMATION—If the spouse of anyoneapplying lives someplace else or is deceased,please indicate below.

NAME OF PERSON APPLYING ____NAME OF SPOUSE ____

DATE OF SPOUSE'S BIRTH ____DATE OF SPOUSE'S DEATH, IF APPLICABLE ____SPOUSE'S SOCIAL SECURITY NUMBER ____

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SPOUSE'S ADDRESS, IF APPLICABLE ____CITY ____COUNTY ____STATE ____ZIP CODE ____

SECTION 13—ABSENT CHILDINFORMATION—If anyone applying has a childunder the age of 21 living someplace else,please indicate below.

NAME OF PERSON APPLYING ____NAME OF ABSENT CHILD ____

DATE OF BIRTH ____ADDRESS OF CHILD (STREET, CITY, COUNTY,STATE, AND ZIP CODE) ____PATERNITY ESTABLISHED?

☐ Yes

☐ NoDO YOU PAY CHILD SUPPORT?

☐ Yes

☐ No


DATE OF BIRTH ____

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ADDRESS OF CHILD (STREET, CITY, COUNTY,STATE, AND ZIP CODE) ____PATERNITY ESTABLISHED?

☐ Yes


☐ Yes

☐ No


DATE OF BIRTH ____ADDRESS OF CHILD (STREET, CITY, COUNTY,STATE, AND ZIP CODE) ____PATERNITY ESTABLISHED?

☐ Yes


☐ Yes

☐ No

SECTION 14—TEEN PARENT INFORMATION

Is there a parent under the age of 18 ("teen parent") in thehousehold?

☐ Yes

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☐ NoName ____

Does the teen parent's child live in the household?

☐ Yes

☐ NoName of teen parent's child ____

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SECTION 15—INCOME INFORMATION:

Indicate if you or anyone who lives with you receivesmoney from:

1 Unemployment Insurance Benefits

☐ YES

☐ NOWHO ____AMOUNT/VALUE & FREQUENCY ____WHO ____AMOUNT/VALUE & FREQUENCY ____

2 Supplemental Security Income (SSI) Benefits (State andFederal Total)

☐ YES

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3 Social Security Disability (SSD) Benefits

☐ YES


4 Social Security Dependent Benefits

☐ YES


5 Social Security Survivor's Benefits

☐ YES


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6 Social Security Retirement Benefits

☐ YES


7 Railroad Retirement Benefits

☐ YES


8 Retirement Benefits (Pensions)

☐ YES


9 Dividends/Interest from Stocks, Bonds, Savings, etc.

☐ YES

☐ NOWHO ____AMOUNT/VALUE & FREQUENCY ____

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WHO ____AMOUNT/VALUE & FREQUENCY ____

10 Workers' Compensation

☐ YES


11 NYS Disability Benefits

☐ YES


12 Veteran's Pension/Benefits/Aid and Attendance

☐ YES


13 Public Assistance Grant

☐ YES

☐ NO

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WHO ____AMOUNT/VALUE & FREQUENCY ____WHO ____AMOUNT/VALUE & FREQUENCY ____

14 GI Dependency Allotments

☐ YES


15 Education Grants or Loans

☐ YES


16 Contributions/Gifts (Received)

☐ YES


17 Foster Care Payments (Received)

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☐ YES


18 Child Support Payments (Received) Received From:____

☐ YES


19 Spousal Support (Received)

☐ YES


20 Private Disability Insurance—Health/AccidentInsurance Policy Income

☐ YES

☐ NOWHO ____

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AMOUNT/VALUE & FREQUENCY ____WHO ____AMOUNT/VALUE & FREQUENCY ____

21 No-Fault Insurance Benefits

☐ YES


22 Union Benefits (including Strike Benefits)

☐ YES


23 Loans, Other than Education (Received)

☐ YES


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24 Income from a Trust (including income you arecurrently entitled to receive, or were entitled to receive inthe past, that has not been distributed)

☐ YES


25 Training Allotments/Stipends

☐ YES


26 Rental Income (Received)

☐ YES


27 Boarders/Lodgers Income (Received)

☐ YES

☐ NO

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WHO ____AMOUNT/VALUE & FREQUENCY ____WHO ____AMOUNT/VALUE & FREQUENCY ____

Other Income (Please Specify) ____

☐ YES


Other Income (Please Specify) ____

☐ YES


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Deductions: Certain types of Medicaid budgeting allowapplicants/recipients to reduce their countable income withdeductions that they take on their federal taxes. These are

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specific expenses that the Internal Revenue Service (IRS)allows people to deduct to reduce their taxable income.Only record deductions here if you will claim them on thecurrent year's tax return.

1 Educator expenses

☐ YES


2 Individual Retirement Account (IRA) deduction

☐ YES


3 Student loan interest deduction

☐ YES


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4 Tuition and fees

☐ YES


5 Certain business expenses (reservists, artists, fee-basedgovernment officials)

☐ YES


6 Health savings account deduction

☐ YES


7 Job-related moving expenses

☐ YES

☐ NOWHO ____

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AMOUNT/VALUE & FREQUENCY ____WHO ____AMOUNT/VALUE & FREQUENCY ____

8 Deductible part of self-employment (S/E) tax

☐ YES


9 S/E, SIMPLE & qualified plans

☐ YES


10 S/E health insurance deduction

☐ YES


11 Penalty on early withdrawal of savings

☐ YES

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12 Alimony paid

☐ YES


13 Domestic production activities deduction

☐ YES


14 Additional adjustments added on line 36 (IRS Form1040 only)

☐ YES

☐ NOWHO ____AMOUNT/VALUE & FREQUENCY ____WHO ____

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AMOUNT/VALUE & FREQUENCY ____15 Archer MSA deduction

☐ YES


Other Adjustment (Please Specify) ____

☐ YES


Other Adjustment (Please Specify) ____

☐ YES


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SECTION 16—STEP-PARENT/NON-CITIZENWITH SATISFACTORY IMMIGRATIONSTATUS SPONSOR INFORMATION

Answer all questions listed below.

Does the step-parent of any children who live with youhave any resources or receive income of any kind?

☐ YES

☐ NOWHO? ____

Is anyone in your household a non-citizen with satisfactoryimmigration status who was sponsored for admission intothe U.S.?

☐ YES

☐ NOWHO? ____

NAME OF SPONSOR: ____PHONE NO.: ____ADDRESS: ____

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SECTION 17—EMPLOYMENT INFORMATION

1 I am currently:

☐ employed

☐ self-employed

☐ unemployedGross Income (Include wages, salary, overtime pay,commissions, and tips) $____Hours Worked Monthly ____Paid:

☐Weekly

☐ Bi-Weekly

☐ MonthlyDay of the week paid: ____Employer's Name and Address: ____Phone No. ____

2 Is anyone else who lives with you currently:

☐ employed

☐ self-employedWho: ____Gross Income $____Hours Worked Monthly ____

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Paid:

☐Weekly

☐ Bi-Weekly

☐ MonthlyDay of the week paid: ____Employer's Name and Address: ____Phone No. ____

3 Is health insurance available through your employer?

☐ Yes

☐ NoDoes anyone who lives with you have health insurancewith an employer?

☐ Yes

☐ NoWho: ____Name of Insurance Company: ____

4 Do you or anyone who lives with you have a child ordependent care expenses due to employment?

☐ Yes

☐ NoWho: ____

5 Do you or anyone who lives with you have otheremployment-related expenses?

☐ Yes

☐ NoWho: ____

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6 If not employed, when was the last time you or anyonewho lives with you worked?

Who: ____When: ____Where: ____Why did you (or they) stop working? ____Did you or anyone living with you file forunemployment?

☐ Yes

☐ NoIf yes, who? ____

When?: ____Status of filing:

☐ Approved

☐ Denied

☐ Pending7 Are you or is anyone who lives with you participating in astrike?

☐ Yes

☐ NoWho: ____When the strike began: ____

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8 Are you or is anyone who lives with you a migrant orseasonal farm worker?

☐ Yes

☐ NoWho: ____

9 Do you or any other adult who lives with you have anymedical conditions that limit the ability to work or the typeof work that can be performed?

☐ Yes

☐ NoWho: ____Describe Limitations: ____

10 Could you accept a job today?

☐ Yes

☐ NoIf not, why? ____

11 What type of work would you like to do? ____

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SECTION 18—EDUCATION/TRAINING

1 What is your highest level of education completed?

☐ Less than high school diploma

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If so, last grade completed? ____

☐ Completion of an Individualized Education Plan (IEP)

☐ High school diploma or General Equivalency Diploma(GED) or Test Assessing Secondary Completion(TASC™)

☐ Associate's Degree (2-year college degree)

☐ Bachelor's Degree (4-year college degree) or higher2 Does anyone else in the household have a high schooldiploma, General Equivalency Diploma (GED) or TestAssessing Secondary Completion (TASC™), or higherlevel of education?

☐ Yes

☐ NoIf yes, who: ____

Degree attained: ____Date completed: ____

Indicate if you or anyone who lives with you who isapplying for or getting assistance:

3 Is or has been in any training program?

☐ Yes

☐ NoWho ____Where ____Program ____Dates attended ____

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Dates completed ____4 Is 16 years of age or older and is attending school orcollege?

☐ Yes

☐ NoWho ____Where ____

5 Is under 16 years of age and is attending school?

☐ Yes

☐ NoWho ____

School ____Who ____

School ____Who ____

School ____Who ____

School ____

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SECTION 19—RESOURCES INFORMATION

Indicate if you or anyone who lives with you who isapplying:

1 Has cash available

☐ YES

☐ NOWHO ____AMOUNT/VALUE ____WHO ____AMOUNT/VALUE ____

2 Has a checking account(s)

☐ YES


3 Has a savings account(s) or certificate(s) of deposit

☐ YES

☐ NOWHO ____

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AMOUNT/VALUE ____WHO ____AMOUNT/VALUE ____

4 Has a credit union account(s)

☐ YES


5 Has life insurance

☐ YES


6 Has title or registration to a motor vehicle(s) or othervehicle(s):

Year ____Make/Model ____Year ____Make/Model ____Other ____

☐ YES

☐ NO

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WHO ____AMOUNT/VALUE ____WHO ____AMOUNT/VALUE ____

7 Has stocks, bonds, certificates or mutual funds

☐ YES


8 Has savings bonds

☐ YES


9 Has an IRA, Keogh, 401(k) or deferred compensationaccount(s)

☐ YES


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10 Has an irrevocable burial trust

☐ YES


11 Has a burial fund

☐ YES


12 Has a burial space

☐ YES


13 Has his/her own home

☐ YES

☐ NOWHO ____AMOUNT/VALUE ____

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WHO ____AMOUNT/VALUE ____

14 Has real estate, including income-producing and non-income-producing property

☐ YES


15 Is eligible for an income tax refund

☐ YES


16 Has an annuity

☐ YES


17 Is the beneficiary of a trust

☐ YES

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18 Expects to receive a trust fund, lawsuit settlement,inheritance or income from any other sources

☐ YES


19 Has an "in trust" account(s)

☐ YES


20 Has a safe deposit box(es)

☐ YES

☐ NOWHO ____AMOUNT/VALUE ____WHO ____

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AMOUNT/VALUE ____21 Has resources other than those listed above

☐ YES


22 Has anyone (including your spouse, even if notapplying or living with you) given away any cash, or sold/transferred any real estate, income or personal property inthe past 36 months?

☐ YES


23 Has anyone (including your spouse, even if notapplying or living with you) ever created a trust in the pastor transferred any assets to a trust within the past 60months?If yes, when? ____

☐ YES

☐ NOWHO ____

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AMOUNT/VALUE ____WHO ____AMOUNT/VALUE ____

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SECTION 20—MEDICAL INFORMATION


1 Has any medical bills or medically-related expenses

☐ YES

☐ NOIF YES, WHO ____

2 Is on Medicaid with a spend-down

☐ YES


3 Has health or hospital/accident insurance (includinginsurance from employer)

☐ YES


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POLICY NO.: ____AMOUNT: ____FREQUENCY OF PAYMENT: ____

4 Has health insurance available through an employer

☐ YES


INSURANCE COMPANY NAME: ____WHO IS COVERED: ____EFFECTIVE DATE: ____

5 Has Medicare (red, white, and blue card)

☐ YES


6 Has a health attendant/home health aide

☐ YES


7 Is blind, sick or disabled

☐ YES


8 Is a child with a developmental disability

☐ YES


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9 Is in a hospital, nursing home or other medical institution

☐ YES


10 Has paid or unpaid medical bills within 3 monthspreceding the month of this application

☐ YES


11 Is or was drug or alcohol dependent

☐ YES


12 Needs home care/personal care

☐ YES


13 Is on SSI or has ever applied for SSI

☐ YES


14 Is pregnantIf pregnant, due date: ____Expected number of births: ____

☐ YES

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15 Receives treatment from a drug abuse or alcoholtreatment program

☐ YES


16 Has not been able to work for at least 12 monthsbecause of a disability or illness

☐ YES


17 Has daily activity limited because of a disability orillness that has lasted or will last at least 12 months

☐ YES


18 Has been in a car accident or work-related accident inthe past two years

☐ YES


19 Has had a government agency (public program)besides Medicaid or Medicare pay any of your medicalbills

If yes, what agency ____

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☐ YES


20 Will billing any other health insurance cause harm toyour physical or emotional health or safety, and/or will itinterfere with the privacy and confidentiality of yourapplication for or receipt of Medicaid?

☐ YES


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HEALTH PLAN SELECTION

Most people enrolled in Medicaid are required to join amanaged care health plan unless they are in an exemptcategory. Use this section to choose a health plan. If youdo not know what health plans are available, ask yourworker or call 1-800-505-5678.

Name of Plan You Are Enrolling In ____Last Name ____First Name ____

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Date Of Birth mm/dd/yy ____Sex M/F ____ID# (from Medicaid Card if you have one) ____Social Security # (optional if pregnant) ____Primary Care Provider (PCP) or Health Center (checkbox if current provider) ____☐Name and ID# of OB/GYN (check box if currentprovider) ____☐

Name of Plan You Are Enrolling In ____Last Name ____First Name ____Date Of Birth mm/dd/yy ____Sex M/F ____ID# (from Medicaid Card if you have one) ____Social Security # (optional if pregnant) ____Primary Care Provider (PCP) or Health Center (checkbox if current provider) ____☐Name and ID# of OB/GYN (check box if currentprovider) ____☐

Name of Plan You Are Enrolling In ____Last Name ____First Name ____Date Of Birth mm/dd/yy ____Sex M/F ____ID# (from Medicaid Card if you have one) ____

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Social Security # (optional if pregnant) ____Primary Care Provider (PCP) or Health Center (checkbox if current provider) ____☐Name and ID# of OB/GYN (check box if currentprovider) ____☐

Name of Plan You Are Enrolling In ____Last Name ____First Name ____Date Of Birth mm/dd/yy ____Sex M/F ____ID# (from Medicaid Card if you have one) ____Social Security # (optional if pregnant) ____Primary Care Provider (PCP) or Health Center (checkbox if current provider) ____☐Name and ID# of OB/GYN (check box if currentprovider) ____☐

SECTION 21—SHELTER

WHAT IS YOUR LANDLORD'S NAME? ____WHAT IS YOUR LANDLORD'S ADDRESS? ____WHAT IS YOUR LANDLORD'S PHONE NUMBER? ____Do you or anyone who lives with you have a rent,mortgage or other shelter expense?

☐ YES

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☐ NOIF YES, AMOUNT $____

Do you or anyone who lives with you have a heat billseparate from your rent or other shelter expense?

☐ YES


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SECTION 21—SHELTER (CONT.)

Do you or anyone who lives with you have the followingexpenses separate from your rent or other shelterexpense?

1 Electricity (for needs other than heat; example: lights,cooking, hot water, etc.)

☐ YES


2 Natural Gas (for needs other than heat; example:cooking, hot water, etc.)

☐ YES

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3 Water

☐ YES


4 Air Conditioning

☐ YES


5 Propane (for needs other than heat)

☐ YES


6 Sewer

☐ YES


7 Trash

☐ YES


8 Other Utilities and ExpensesSpecify ____

☐ YES

☐ NO

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IF YES, AMOUNT $____9 Do you live in public housing?

☐ YES

☐ NO10 Do you live in Section 8, HUD, or other subsidizedhousing?

☐ YES

☐ NO11 Do you live in a drug/alcohol treatment facility?

☐ YES

☐ NO

ADDITIONAL INFORMATION

SECTION 22—OTHER EXPENSES


1 Pays child support

☐ YES


2 Pays spousal support

☐ YES

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3 Pays for child care

☐ YES


4 Pays for dependent care

☐ YES


5 Pays tuition, fees, or other educational expenses

☐ YES


6 Has additional expenses (Example: car payment, carinsurance payment, credit card payments, other loanpayments, etc.)Specify: ____

☐ YES


7 Do you or anyone who lives with you who is applyingowe at least four months of support for a child under theage of 21?

☐ YES

☐ NO

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SECTION 23—OTHER INFORMATION

8 Do you buy or plan to buy meals from a home delivery orcommunal dining service?

☐ YES

☐ NO9 Are you able to cook or prepare meals at home?

☐ YES

☐ NO10 Have you or anyone in your household ever been in theU.S. military?

Who? ____

☐ YES

☐ NO

11 Has your spouse ever been in the U.S. military?

☐ YES

☐ NO12 Is anyone in your household a dependent of someonewho is or was in the U.S. military?

Who? ____

☐ YES

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☐ NO13 Do you or does anyone who lives with you receiveassistance or services now?

☐ YES

☐ NO

IF YES, WHO ____TYPE OF ASSISTANCE ____IF YES, WHO ____TYPE OF ASSISTANCE ____

14 Have you or anyone who lives with you receivedassistance or services in the past?

☐ YES

☐ NO

IF YES, WHO (Please list all previous names) ____TYPE OF ASSISTANCE ____IF YES, WHO (Please list all previous names) ____TYPE OF ASSISTANCE ____IF YES, WHO (Please list all previous names) ____TYPE OF ASSISTANCE ____

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OTHER INFORMATION (CONT.)

Have you or anyone who lives with you who is applyingmoved into this county from another New York Statecounty within the past two months?

☐ YES

☐ NOWHO ____

Have you or anyone who lives with you ever been foundguilty of and/or been disqualified for Public Assistanceand/or the Supplemental Nutrition Assistance Program(SNAP) because of fraud/an Intentional ProgramViolation?

☐ YES

☐ NOWHO ____

Have you or anyone who lives with you received benefitsfor which they were not entitled, which have not been fullyrepaid to this or another agency?

☐ YES

☐ NOWHO ____

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Have you or any member of your household beenconvicted of making a fraudulent statement orrepresentation of residence in order to receive PublicAssistance in two or more states?

☐ YES

☐ NOWHO ____

Have you or any member of your household beenconvicted of fraudulently receiving duplicate SNAPBenefits in any state after September 22, 1996?

☐ YES

☐ NOWHO ____

Have you or any member of your household beenconvicted of buying or selling SNAP Benefits for acombined amount of over $500 or more after September22, 1996?

☐ YES

☐ NOWHO ____

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Have you or any member of your household beenconvicted of trading SNAP benefits for firearms,ammunition or explosives, or drugs?

☐ YES

☐ NOWHO ____

Are you or any member of your household fleeing to avoidprosecution, custody or confinement after conviction of afelony or attempted felony and actively being pursued bylaw enforcement?

☐ YES

☐ NOWHO ____

Are you or any member of your household violatingprobation or parole according to a court order?

☐ YES

☐ NOWHO ____

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PROPERTY TRANSFER STATUS

I have☐ I have not☐ sold, transferred or given awayany of my property to anyone to get Public Assistance orSNAP Benefits.

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NOTICES, ASSIGNMENTS,AUTHORIZATIONS, and CONSENTS

COLLECTION AND USE OF SOCIAL SECURITYNUMBERS—The collection of Social Security Numbers(SSNs) is authorized for each household member withrespect to the Supplemental Nutrition Assistance Program(SNAP), pursuant to the Food and Nutrition Act of 2008(as amended). Anyone applying for SNAP must provide an

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SSN in order to receive benefits. If you or anyone applyingdoes not have an SSN, that person must apply for an SSNwith the Social Security Administration (visit www.SSA.govor call 1-800-772-1213).

With respect to all other programs for which thisapplication form requires an SSN, the collection of SSNsis also mandatory and is authorized under one or more ofthe following sections of law: Section 205(c) of the SocialSecurity Act (42 U.S. Code 405), Section 1137 of theSocial Security Act (42 U.S. Code 1320b-7) and Section7(a)(2) of the Privacy Act of 1974. See the instruction book(PUB-1301 Statewide) or talk to your social servicesdistrict if you have questions.

The information we collect will be used to determinewhether your household is eligible or continues to beeligible for assistance or benefits. The information will beused to check identity, to verify earned and unearnedincome, to determine if absent parents can receive healthinsurance coverage for applicants or recipients, todetermine if applicants or recipients can obtain child orspousal support, and to determine if applicants orrecipients can receive money or other help. We will verifythis information through computer matching programs.This information will also be used to monitor compliancewith program regulations and for program management.

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Besides using the information you give us in this way, thestate will use the information to prepare statistics about allof the people receiving benefits from the Home EnergyAssistance Program (HEAP) (see below).

This information may be disclosed to other state andfederal agencies for official examination and to lawenforcement officials for the purpose of apprehendingpersons fleeing to avoid the law. Information collected withrespect to applicants for and recipients of FamilyAssistance and Safety Net Assistance, including SSNs,may be used to assist in the formation of jury pools. If aSNAP claim arises against your household, theinformation on this application, including all SSNs, may bereferred to federal and state agencies, as well as privateclaims collection agencies, for claims collection action.

SSNs of ineligible household members will also be usedand disclosed in the manner above.

Besides using the information you give us in this way, theState also uses the information to prepare statistics aboutall the people receiving benefits from HEAP. Theinformation is used for quality control by the State to makesure social services districts are doing the best job theycan. It is used to verify your energy supplier and to makecertain payments to such vendors.

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NONDISCRIMINATION NOTICE—This institution isprohibited from discriminating on the basis of race, color,national origin, disability, age, sex and, in some cases,religion or political beliefs.

The United States Department of Agriculture (USDA) alsoprohibits discrimination based on race, color, nationalorigin, sex, religious creed, disability, age, political beliefsor reprisal or retaliation for prior civil rights activity in anyprogram or activity conducted or funded by USDA.

Persons with disabilities who require alternative means ofcommunication for program information (e.g. Braille, largeprint, audiotape, American Sign Language, etc.), shouldcontact the agency (State or local) where they applied forbenefits. Individuals who are deaf, hard of hearing or havespeech disabilities may contact USDA through the FederalRelay Service at (800) 877-8339. Additionally, programinformation may be made available in languages otherthan English.

To file a Supplemental Nutrition Assistance Program(SNAP) complaint of discrimination, complete the USDAProgram Discrimination Complaint Form, (AD-3027),found online at:http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, orwrite a letter addressed to USDA and provide in the letter

92

all of the information requested in the form. To request acopy of the complaint form, call (866) 632-9992. Submityour completed form or letter to USDA by:

1. Mail: U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410

2. Fax: (202) 690-7442; or

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3. Email: [email protected].

For any other information dealing with SupplementalNutrition Assistance Program (SNAP) issues, personsshould either contact the USDA SNAP Hotline Number at(800) 221-5689, which is also in Spanish, or call the StateInformation/Hotline Numbers (click the link for a listing ofhotline numbers by State); found online at:http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

To file a complaint of discrimination regarding a programreceiving federal financial assistance through the U.S.

93

Department of Health and Human Services (HHS), writeHHS Director, Office for Civil Rights, Room 515-F, 200Independence Avenue, S.W., Washington, D.C. 20201, orcall (202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

CONSENT FOR INVESTIGATION—I agree to anyinvestigation to verify or confirm the information I havegiven in connection with my request for Public Assistance(PA), Medicaid, Supplemental Nutrition AssistanceProgram (SNAP) Benefits, Home Energy AssistanceProgram Benefits, Services or Child Care Assistance. Ifadditional information is requested, I will provide it. I willalso cooperate fully with state and federal personnel inany PA and/or SNAP Quality Control Review.

If I am applying for SNAP, I understand that the socialservices district will request and use information availablethrough the Income and Eligibility Verification System toinvestigate my application, and may verify this informationthrough collateral contacts if discrepancies are found. Ialso understand that such information may affect myeligibility for SNAP and/or the level of SNAP Benefits Ireceive.

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CONSENT FOR RELEASE OF CONFIDENTIALUNEMPLOYMENT INSURANCE INFORMATION—Iauthorize the New York State Department of Labor (DOL)to release any confidential information maintained by DOLfor Unemployment Insurance (UI) purposes to the NewYork State Office of Temporary and Disability Assistance(OTDA). This information includes UI benefit claims andwage records. I understand that OTDA, along with stateand local agency employees working in social servicesdistrict offices, will use the UI information for establishingor verifying eligibility for, and the amount of, PublicAssistance, Medicaid, Supplemental Nutrition AssistanceProgram Benefits, Home Energy Assistance ProgramBenefits or Child Care Assistance, applied for in thisapplication and for investigations to determine whether Ireceived benefits to which I was not entitled. OTDA mayalso share the information with the New York State Officeof Children and Family Services (OCFS) and the New YorkState Department of Health (DOH). OCFS will use theinformation to monitor the Child Care Assistance program.

RELEASE OF INFORMATION TO SERVICEPROVIDERS—I give permission to the social servicesdistrict and New York State to share information regardingPublic Assistance or Supplemental Nutrition AssistanceProgram benefits that I or any member of my household

95

for whom I can legally give authorization have received,for purposes of verifying my eligibility for services andpayment related to program administration provided by aState or local contractor. Such services may include, butare not limited to, job placement or training servicesprovided to help me or members of my household obtainand retain employment.

CHANGE REPORTING—I agree to inform the agencypromptly of any change in my address, needs, income,and property, able-bodied adult without dependents(ABAWD) status, pregnancy status or living arrangements,to the best of my knowledge or belief.

If I am applying for Child Care Assistance, I agree toinform the agency immediately of any change in familyincome, who lives in my home, employment, child carearrangements or other changes which may affect mycontinued eligibility or amount of my benefit.

PENALTIES—Federal and state laws provide for penaltiesof fine, imprisonment or both if you do not tell the truthwhen you apply for Public Assistance, Medicaid,Supplemental Nutrition Assistance Program, Services orChild Care Assistance ("Assistance, Benefits or Services")or at any time when you are questioned about youreligibility, or cause someone else not to tell the truth

96

regarding your application or your continuing eligibility.Penalties also apply if you conceal or fail to disclose factsregarding your initial and continuing eligibility for

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Assistance, Benefits or Services, or if you conceal or fail todisclose facts that would affect the right of someone forwhom you have applied to obtain or continue to receiveAssistance, Benefits or Services. If you are an authorizedrepresentative, such Assistance, Benefits or Servicesmust be used for the other person and not for yourself.Federal and state laws provide that any transfer of assetsfor less than fair market value made by an individual or anindividual's spouse, within 60 months prior to the first ofthe month in which the individual is both in receipt ofnursing facility services and has submitted an applicationfor Medicaid, may render the individual ineligible fornursing facility services or home and community-basedwaivered services for a period of time. It is unlawful toobtain Assistance, Benefits or Services by concealinginformation or providing false information.

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SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAMDISQUALIFICATION PENALTIES—Any information youprovide in connection with your application for theSupplemental Nutrition Assistance Program (SNAP) willbe subject to verification by federal, state and localofficials. If any information is incorrect, you may be deniedSNAP Benefits. You may be subject to criminalprosecution if you knowingly provide incorrect informationwhich affects eligibility or the amount of benefits. Anyperson convicted of a felony for knowingly using,transferring, acquiring, altering or possessing SNAPauthorization cards or access devices may be fined up to$250,000, imprisoned up to 20 years or both. Theindividual may also be subject to prosecution under theapplicable federal and state laws. Anyone who is violatinga condition of probation or parole, or anyone who is fleeingto avoid prosecution, custody or confinement of a felonyand is actively being pursued by law enforcement, is noteligible to receive SNAP Benefits.

You may be found ineligible for SNAP or found to havecommitted an Intentional Program Violation (IPV) if youmake a false or misleading statement, or misrepresent,conceal or withhold facts, in order to qualify for benefits orreceive more benefits; purchase a product with SNAPbenefits with the intent of obtaining cash by intentionally

98

discarding the product and returning the container for thedeposit amount; or commit or attempt to commit any actthat constitutes a violation of federal or state law for thepurpose of using, presenting, transferring, acquiring,receiving, possessing or trafficking SNAP Benefits,authorization cards or reusable documents used as part ofthe Electronic Benefit Transfer (EBT) system. Additionally,the following is not allowed and you may be disqualifiedfrom receiving SNAP Benefits and/or be subject topenalties for actions that include:

• Using SNAP benefits to buy non-food items, such asalcohol or cigarettes;

• Using SNAP benefits to pay for food previouslypurchased on credit;

• Allowing someone else to use your EBT card inexchange for cash, firearms, ammunition or explosives,or drugs, or to purchase food for individuals who are notmembers of your SNAP household; or

• Using or having in your possession EBT cards that donot belong to you, without the card owner's consent.

Individuals found to have committed an IPV either throughan administrative disqualification hearing or by a federal,State or local court, or have signed either a waiver of rightto an administrative disqualification hearing or adisqualification consent agreement in cases referred for

99

prosecution shall be ineligible to participate in SNAP for aperiod of:

• 12 months for the first SNAP IPV;• 24 months for the second SNAP IPV;• 24 months for the first SNAP IPV that is based on a

court finding that the individual used or received SNAPBenefits in a transaction involving the sale of acontrolled substance (illegal drugs or certain drugs forwhich a doctor's prescription is required); or

• 120 months if the individual is found to have made afraudulent statement about who he/she is or where he/she lives in order to get multiple SNAP Benefitssimultaneously, unless permanently disqualified for athird SNAP IPV.

Additionally, a court may bar an individual fromparticipating in SNAP for an additional 18 months.

An individual can be permanently disqualified fromreceiving SNAP Benefits for:

• The first SNAP IPV based on a court finding that theindividual used or received SNAP Benefits in atransaction involving the sale of firearms, ammunition orexplosives;

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• The first SNAP IPV based on a court conviction fortrafficking SNAP Benefits for a combined amount of$500 or more (trafficking includes the illegal use,transfer, acquisition, alteration or possession of SNAPauthorization cards or access devices);

• The second SNAP IPV based on a court finding that theindividual used or received SNAP Benefits in atransaction involving the sale of a controlled substance(illegal drugs or certain drugs for which a doctor'sprescription is required); or

• A third SNAP IPV.

REQUIREMENT TO REPORT/VERIFY HOUSEHOLDEXPENSES—Your household must report child care andutility expenses in order to get a Supplemental NutritionAssistance Program (SNAP) deduction for theseexpenses. Your household must report and verify rent/mortgage payments, property taxes, insurance, medicalexpenses and child support paid to a non-householdmember in order to get a SNAP deduction for theseexpenses. Failure to report/verify the above expenses willbe seen as a statement by your household that you do notwant to receive a deduction for these unreported/unverified expenses. A deduction for these expenses maymake you eligible for SNAP or may increase your SNAPbenefits. You

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may report/verify these expenses at any time in the future.The deduction would then be applied to the calculation ofSNAP benefits in future months, in accordance with therules for change reporting (see Change Reporting, above).

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAMAUTHORIZED REPRESENTATIVE—You can authorizesomeone who knows your household circumstances toapply for Supplemental Nutrition Assistance Program(SNAP) Benefits for you. You can also authorize someoneoutside your household to get SNAP Benefits for you or touse them to buy food for you. If you would like to authorizesomeone, you must do so in writing. You may authorizesomeone by printing the person's name, address, andphone number immediately below, and having them signin the signature section at the end of this application.When an Authorized Representative is applying on behalfof a SNAP household that does not reside in an institution,both the Authorized Representative and a responsibleadult member of the household must sign and date thesignature section at the end of this application, unless theSNAP household has otherwise designated the AuthorizedRepresentative to do so in writing.

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NAME, ADDRESS AND PHONE NUMBER OFAUTHORIZED REPRESENTATIVE (PLEASE PRINT):____

STANDARD UTILITY ALLOWANCE—I understand thatPublic Assistance and Supplemental Nutrition AssistanceProgram (SNAP) recipients are categorically incomeeligible for the Home Energy Assistance Program (HEAP).I also understand that if I have not received a HEAPbenefit of greater than $20 in the current month orprevious 12 months, or a similar energy assistancebenefit, I must pay for heating or air conditioningseparately from my rent in order to receive the heating/cooling standard utility allowance (i.e., a deduction) forSNAP. I understand that the State will use my SocialSecurity Number to verify with my home energy vendorsthe receipt of HEAP. This authorization also includespermission for any of my home energy vendors (includingmy utility) to release certain statistical information,including but not limited to, my annual electricity usage,electricity cost, fuel consumption, fuel type, annual fuelcost and payment history to the New York State Office ofTemporary and Disability Assistance, the local socialservices district and the United States Department ofHealth and Human Services for the purposes of Low

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Income Home Energy Assistance Program performancemeasurement.

RELEASE OF MEDICAL INFORMATION—I consent tothe release of any medical information about me and anymembers of my family for whom I can give consent by myprimary care provider, any other health care provider orthe New York State Department of Health (DOH) to myhealth plan and any health care providers involved incaring for me or my family, as reasonably necessary formy health plan or my providers to carry out treatment,payment, or health care operations; by my health plan andany health care providers to DOH and other authorizedfederal, state, and local agencies for purposes ofadministration of Medicaid; and, by my health plan to otherpersons or organizations, as reasonably necessary for myhealth plan to carry out treatment, payment, or health careoperations. I authorize the release of any health-relatedinformation about me and any members of my family forwhom I can legally give authorization related to theprovision of assistance and services and my ability toparticipate in work activities, including employment, to theNew York State Office of Temporary and DisabilityAssistance (OTDA), the New York State Office of Childrenand Family Services or the local social services district, asreasonably necessary for the provision of Public

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Assistance benefits; for services, including child welfareservices; for determining appropriate work activityassignments; for determining the need to apply and formaking application for Supplemental Security IncomeBenefits; for establishing appropriate treatment plans forrestoring employability; and for determining eligibility forexemptions from the State sixty-month time limit on cashassistance receipt. If I am required to apply for benefitsadministered by the Social Security Administration, theinformation specified above may be shared with the SocialSecurity Administration. I also agree that the informationreleased may include HIV, mental health or alcohol andsubstance abuse information about me and members ofmy family, to the extent permitted by law, unless a box ischecked below. If more than one adult in the family isjoining a Medicaid health plan, the signature of each adultapplying is necessary for consent to release information. Iunderstand that my ability to consent to the release ofinformation relating to any minor children for whom I maygive consent is limited by the extent to which I can obtaininformation regarding treatment, diagnosis and procedureson their behalf.

☐ Do not disclose HIV/AIDS information

☐ Do not disclose drug and alcohol information

☐ Do not disclose mental health information

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RELEASE OF EDUCATIONAL RECORDS—I givepermission to the New York State Department of Healthand the social services district to:1) obtain any informationregarding the educational records of myself and/or myminor child(ren), herein named, including informationnecessary for claiming Medicaid reimbursement for health-related educational services; and 2) provide theappropriate federal government agency access to thisinformation for the sole purpose of audit.

RELEASE OF INFORMATION FOR THE EARLYINTERVENTION PROGRAM—If my child is evaluated foror participates in the New York State Early InterventionProgram, I give permission to the social services districtand New York State to share my child's Medicaid eligibilityinformation with my county or municipal Early InterventionProgram for the purpose of billing Medicaid.

CHILD/TEEN HEALTH PROGRAM—I understand that ifmy child is on Medicaid, he or she can get comprehensiveprimary and preventive care, including all necessarytreatment through the Child/Teen Health Program. I can

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get more information on this program from the socialservices district.

MEDICARE—I authorize payments under "Medicare" (PartB of Title XVIII, Supplementary Medical InsuranceProgram) to be made directly to physicians and medicalsuppliers on any future unpaid bills for medical and otherhealth services furnished to me while I am eligible forMedicaid.

REIMBURSEMENT OF MEDICAL EXPENSES

MEDICAID—You have a right as part of your Medicaidapplication, or within two years from the date of yourapplication, to request reimbursement of expenses youpaid for covered medical care, services and suppliesreceived during the three-month period prior to the monthof your application. After the date of your application,reimbursement of covered medical care, services andsupplies will only be available if obtained from Medicaid-enrolled providers.

ASSIGNMENT OF INSURANCE/OTHER BENEFITSAND DIRECT PAYMENT—For Public Assistance andMedicaid, I agree to file any claims for health or accidentinsurance benefits, and to pursue any personal injury

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claims or any other resources to which I may be entitled,and do hereby assign any such resources to the socialservices district to whom this application is made. Inaddition, I will assist in making any assigned benefitsavailable to the social services district to whom thisapplication is made.

I authorize payments owed to me or members of myhousehold for health or accident insurance benefits to bemade directly to the appropriate social services district formedical and other health services furnished while we areeligible for Medicaid.

MEDICAID RECOVERIES—Upon receipt of Medicaid, alien may be filed and a recovery may be made againstyour real property under certain circumstances if you arein a medical institution and not expected to return home.MA paid on your behalf may be recovered from personswho had legal responsibility for your support at the timemedical services were obtained. MA may also recover thecost of services and premiums incorrectly paid.

I understand that effective April 1, 2014, if I get Medicaidthrough New York State of Health:

• No lien will be placed on my real property prior to mydeath.

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• Recovery from assets in my estate upon my death islimited to the amount Medicaid paid for the cost ofnursing home care, home and community-basedservices, and related hospital and prescription drugservices received on or after my 55th birthday.

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PUBLIC ASSISTANCE RECOVERIES—PublicAssistance (PA) you receive for yourself and for personsfor whom you are legally responsible to support isrecoverable from property or money you possess or mayacquire. You may be required, as a condition of receivingPA, to execute a deed or mortgage of real property youown. Your tax refunds and portions of lottery winnings maybe taken to repay your debt for PA.

AUTHORIZATION TO REPAY PUBLIC ASSISTANCEBENEFITS FROM RETROACTIVE SUPPLEMENTALSECURITY INCOME—I authorize the Commissioner ofthe Social Security Administration (SSA) to use my firstpayment of Supplemental Security Income (SSI); i.e. myretroactive SSI payment) to reimburse the local socialservices district (SSD) for Public Assistance (PA) the SSD

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pays me from State or local funds while SSA decides if Iam eligible for SSI. SSA will not reimburse the SSD for PAthat was paid using any federal funds.

I will be bound by this authorization only if the State givesnotice to SSA that I and an SSD representative havesigned it. The State must give notice within 30 calendardays of matching my SSI record with my State record.SSA will not accept it after 30 calendar days. Instead, SSAwill send me my retroactive SSI payment under SSA rules.

Only my first payment of SSI can be used. If my firstpayment is larger than the amount owed to the SSD, SSAwill send the rest to me under its rules.

SSA can reimburse the SSD in two situations:

(1) It will repay the SSD if I apply for SSI and SSA findsme eligible.(2) It will repay the SSD if my SSI benefits are reinstatedafter termination or suspension.

SSA will only reimburse the SSD for PA it paid me duringthe time I am waiting for an SSA determination of eligibility.This is called "interim assistance." The period begins: 1)with the first month I become eligible for payment of SSIbenefits; or 2) on the first day I am reinstated after my SSI

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was suspended or terminated. The period includes themonth SSI payments actually begin. If the SSD cannotstop my last PA payment, the period ends the next month.

No later than 10 days after SSA reimburses the SSD, theSSD must send me a notice telling me the amount ofinterim assistance paid. The notice will also tell me thatSSA will send me a letter telling me how any remainingSSI money owed to me will be sent by SSA and that, if Ido not agree with a state decision, how I can appeal thedecision to the state.

Under its rules, SSA may use the date I sign thisauthorization as the date I first become eligible for SSI. Itwill do this only if I apply for SSI within the next 60 days.

This authorization applies to any SSI application or appealI now have pending before SSA. This authorizationterminates if my SSI case is completely decided. Itterminates when SSA first pays me. The State and I canalso agree to terminate the authorization. I must sign anew authorization consistent with NYS rules if I reapply forSSI after this authorization terminates, or if I file a new SSIclaim while I have an SSI application or appeal pending.

I will be given an opportunity for a fair hearing if I disagreewith a decision the SSD made about reimbursement.

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I received a copy of the pamphlet called "What You shouldKnow About Social Services Programs." I understand whatit says about interim assistance.

SUPPORT—Applying for or receiving Family Assistance(FA), Safety Net Assistance (SNA) or Title IV-E foster careoperates as an assignment to the State and the socialservices district of any rights to support from any otherperson that the applicant or recipient may have in his orher own right or on behalf of any other family member forwhom the applicant or recipient is applying for, orreceiving, assistance (Social Services Law, Sections 158and 348). This assignment is limited in certain situations.Other sections of this application contain additionalassignments.

ASSIGNMENT OF SUPPORT RIGHTS—I assign to thestate and social services district any rights I have tosupport from persons having legal responsibility for mysupport and any rights I have to support on behalf of anyfamily member for whom I am applying for or receivingassistance. Where applying for or receiving FamilyAssistance or Safety Net Assistance, my assignment ofsupport rights is limited to support which accrues duringthe period that I and/or any family member receivesassistance. However, any support rights that I assigned to

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the state on behalf of myself or any family member prior toOctober 1, 2009, continue to be assigned to the state.

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HOME ENERGY ASSISTANCE PROGRAM—Iunderstand that by signing this application/certification, Iconsent to any investigation to verify or confirm theinformation I have given and other investigation by anyauthorized government agency in connection with HomeEnergy Assistance Program (HEAP) benefits. I alsoconsent to allow the information provided on thisapplication to be used in referrals to availableweatherization assistance programs and my utilitycompany's low income programs.

I understand that the State will use my Social SecurityNumber to verify with my home energy vendors the receiptof HEAP. This authorization also includes permission forany of my home energy vendors (including my utility) torelease certain statistical information, including but notlimited to, my annual electricity usage, electricity cost, fuelconsumption, fuel type, annual fuel cost and paymenthistory to the New York State Office of Temporary and

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Disability Assistance, the local social services district andthe United States Department of Health and HumanServices for the purposes of Low Income Home EnergyAssistance Program performance measurement.

SEXUAL ASSAULT INFORMATION—If you are a victimof sexual assault, you have the right to request referralinformation from the social services district. If you requestreferral information, the social services district mustprovide you with the addresses and phone numbers ofany: 1) local hospitals offering sexual assault forensicexaminer services certified by the NYS Department ofHealth; 2) local rape crisis centers; and 3) local advocacy,counseling, and hotline services appropriate for victims ofsexual assault. In addition, the social services district mustprovide you with the NYS Hotline for Sexual Assault andDomestic Violence numbers: (800) 942-6906 and (800)818-0656 (TTY).

CERTIFICATION FOR CHILD CARE ASSISTANCE—If Iam applying for Child Care Assistance, I certify that myfamily's income does not exceed 85 percent of the Statemedian income for a family of the same size, and myfamily resources do not exceed $1,000,000.

I have read and understand the notices above. Iunderstand and agree to the assignments,

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authorizations and consents above. I swear and/oraffirm under the penalties of perjury that theinformation I have given or will give to the socialservices district is complete and correct.

APPLICANT SIGNATURE ____DATE SIGNED ____

SPOUSE OR PROTECTIVE REPRESENTATIVESIGNATURE ____

DATE SIGNED ____AUTHORIZED REPRESENTATIVE SIGNATURE ____

DATE SIGNED ____

I Consent to Withdraw My Application For:

☐ Public Assistance (PA)

☐ Child Care in lieu of PA

☐ Supplemental Nutrition Assistance Program (SNAP)

☐ Medicaid and SNAP

☐ Medicaid and PA

☐ Services, including Foster Care

☐ Child Care Assistance

☐ Emergency Assistance Only

I understand that I may reapply at any time.

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APPLICANT/AUTHORIZED REPRESENTATIVESIGNATURE ____

DATE SIGNED ____

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NEW YORK STATE APPLICATION FOR CERTAIN BENEFITS … · NEW YORK STATE APPLICATION FOR CERTAIN...

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