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Forms

Overview

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Application for Certain Benefits and Services

Common application for Public Assistance, Child Care in Lieu of Public Assistance, the Supplemental Nutrition Assistance Program ( SNAP ), Medicaid and SNAP , Medicaid and Public Assistance, Services included Foster Care, Child Care Assistance, and Emergency Assistance only.

• Application for Certain Benefits and Services (LDSS-2921)
  • LDSS-2921 - Arabic, LDSS-2921 - Bengali, LDSS-2921 - Chinese, LDSS-2921 - French, LDSS-2921 - Haitian Creole, LDSS-2921 - Italian, LDSS-2921 - Korean, LDSS-2921 - Polish, LDSS-2921 - Russian, LDSS-2921 - Spanish, LDSS-2921 - Urdu, LDSS-2921 - Yiddish
  • PUB-1301 - Arabic, PUB-1301 - Bengali, PUB-1301 - Chinese, PUB-1301 - French, PUB-1301 - Haitian Creole, PUB-1301 - Italian, PUB-1301 - Korean, PUB-1301 - Polish, PUB-1301 - Russian, PUB-1301 - Spanish, PUB-1301 - Urdu, PUB-1301 - Yiddish

  Recertification Form for Certain Benefits and Services

  Recertification form for Public Assistance, Supplemental Nutrition Assistance Program ( SNAP ), Medicaid and SNAP , and Medicaid and Public Assistance.

  • Recertification Form for Certain Benefits and Services (LDSS-3174)
    • LDSS-3174 - Arabic, LDSS-3174 - Bengali, LDSS-3174 - Chinese, LDSS-3174 - French, LDSS-3174 - Haitian Creole, LDSS-3174 - Italian, LDSS-3174 - Korean, LDSS-3174 - Polish, LDSS-3174 - Russian, LDSS-3174 - Spanish, LDSS-3174 - Urdu, LDSS-3174 - Yiddish
    • PUB-1313 - Arabic, PUB-1313 - Bengali, PUB-1313 - Chinese, PUB-1313 - French, PUB-1313 - Haitian Creole, PUB-1313 - Italian, PUB-1313 - Korean, PUB-1313 - Polish, PUB-1313 - Russian, PUB-1313 - Spanish, PUB-1313 - Urdu, PUB-1313 - Yiddish

    Supplemental Nutrition Assistance Program ( SNAP ) Benefits

    • SNAP Application/Recertification (LDSS-4826)
      • LDSS-4826 - Arabic, LDSS-4826 - Bengali, LDSS-4826 - Chinese, LDSS-4826 - French, LDSS-4826 - Haitian Creole, LDSS-4826 - Italian, LDSS-4826 - Korean, LDSS-4826 - Polish, LDSS-4826 - Russian, LDSS-4826 - Spanish, LDSS-4826 - Urdu, LDSS-4826 - Yiddish
      • LDSS-4826A - Arabic, LDSS-4826A - Bengali, LDSS-4826A - Chinese, LDSS-4826A - French, LDSS-4826A - Haitian Creole, LDSS-4826A - Italian, LDSS-4826A - Korean, LDSS-4826A - Polish, LDSS-4826A - Russian, LDSS-4826A - Spanish, LDSS-4826A - Urdu, LDSS-4826A - Yiddish
      • LDSS-2291 - English/Arabic, LDSS-2291 - English/Bengali, LDSS-2291 - English/Chinese, LDSS-2291 - English/Haitian Creole, LDSS-2291 - English/Italian, LDSS-2291 - English/Korean, LDSS-2291 - English/Polish, LDSS-2291 - English/Russian, LDSS-2291 - English/Spanish, LDSS-2291 - English/Yiddish
      • LDSS-4942 - Arabic, LDSS-4942 - Bengali, LDSS-4942 - Chinese, LDSS-4942 - French, LDSS-4942 - Haitian Creole, LDSS-4942 - Italian, LDSS-4942 - Korean, LDSS-4942 - Polish, LDSS-4942 - Russian, LDSS-4942 - Spanish, LDSS-4942 - Urdu, LDSS-4942 - Yiddish
      • LDSS-3151 - Arabic, LDSS-3151 - Bengali, LDSS-3151 - Chinese, LDSS-3151 - Haitian Creole, LDSS-3151 - Italian, LDSS-3151 - Korean, LDSS-3151 - Polish, LDSS-3151 - Russian, LDSS-3151 - Spanish, LDSS-3151 - Yiddish
      • LDSS-5166 - Arabic, LDSS-5166 - Bengali, LDSS-5166 - Chinese, LDSS-5166 - French, LDSS-5166 - Haitian Creole, LDSS-5166 - Italian, LDSS-5166 - Korean, LDSS-5166 - Polish, LDSS-5166 - Russian, LDSS-5166 - Spanish, LDSS-5166 - Urdu, LDSS-5166 - Yiddish

      SCAM Alert

      Summer EBT

      Most families do NOT need to apply for Summer EBT and will be issued benefits automatically. For those who do need to apply, Summer EBT applications should be submitted using the online application, on the Summer EBT webpage whenever possible. If you are unable to apply online, you can apply using the below application. This form must be downloaded, printed, completed, and mailed to the address listed on the top of the application. The deadline to mail a completed application is September 3, 2024.

      • NYS Summer EBT Household Application (OTDA-5250)
        • OTDA-5250 - Arabic, OTDA-5250 - Bengali, OTDA-5250 - Chinese, OTDA-5250 - French, OTDA-5250 - Haitian Creole, OTDA-5250 - Italian, OTDA-5250 - Korean, OTDA-5250 - Polish, OTDA-5250 - Russian, OTDA-5250 - Spanish, OTDA-5250 - Urdu, OTDA-5250 - Yiddish

        Home Energy Assistance Program (HEAP)

        The HEAP application is available when HEAP is open.

        • Home Energy Assistance Program (HEAP) Application (LDSS-3421)
          • LDSS-3421 - Arabic, LDSS-3421 - Bengali, LDSS-3421 - Chinese, LDSS-3421 - French, LDSS-3421 - Haitian Creole, LDSS-3421 - Italian, LDSS-3421 - Korean, LDSS-3421 - Polish, LDSS-3421 - Russian, LDSS-3421 - Spanish, LDSS-3421 - Urdu, LDSS-3421 - Yiddish
          • LDSS-4998 Arabic, LDSS-4998 Bengali, LDSS-4998 Chinese, LDSS-4998 French, LDSS-4998 Haitian Creole, LDSS-4998 Italian, LDSS-4998 Korean, LDSS-4998 Polish, LDSS-4998 Russian, LDSS-4998 Spanish, LDSS-4998 Urdu, LDSS-4998 Yiddish

          State Supplement Program (SSP)

          • Living Arrangement Form (LDSS-5030)
            • LDSS-5030 Arabic, LDSS-5030 Bengali, LDSS-5030 Chinese, LDSS-5030 French, LDSS-5030 Haitian Creole, LDSS-5030 Italian, LDSS-5030 Korean, LDSS-5030 Polish, LDSS-5030 Russian, LDSS-5030 Spanish, LDSS-5030 Urdu, LDSS-5030 Yiddish
            • LDSS-5025 Arabic, LDSS-5025 Bengali, LDSS-5025 Chinese, LDSS-5025 French, LDSS-5025 Haitian Creole, LDSS-5025 Italian, LDSS-5025 Korean, LDSS-5025 Polish, LDSS-5025 Russian, LDSS-5025 Spanish, LDSS-5025 Urdu, LDSS-5025 Yiddish
            • LDSS-5067 Arabic, LDSS-5067 Bengali, LDSS-5067 Chinese, LDSS-5067 French, LDSS-5067 Haitian Creole, LDSS-5067 Italian, LDSS-5067 Korean, LDSS-5067 Polish, LDSS-5067 Russian, LDSS-5067 Spanish, LDSS-5067 Urdu, LDSS-5067 Yiddish
            • LDSS-5040 Arabic, LDSS-5040 Bengali, LDSS-5040 Chinese, LDSS-5040 French, LDSS-5040 Haitian Creole, LDSS-5040 Italian, LDSS-5040 Korean, LDSS-5040 Polish, LDSS-5040 Russian, LDSS-5040 Spanish, LDSS-5040 Urdu, LDSS-5040 Yiddish
            • LDSS-5024 Arabic, LDSS-5024 Bengali, LDSS-5024 Chinese, LDSS-5024 Frenchc, LDSS-5024 Haitian Creole, LDSS-5024 Italian, LDSS-5024 Korean, LDSS-5024 Polish, LDSS-5024 Russian, LDSS-5024 Spanish, LDSS-5024 Urdu, LDSS-5024 Yiddish
            • Rights and Responsibilities of Designated Representatives for the State Supplement Program (LDSS-5032)
            • LDSS-5023 Arabic, LDSS-5023 Bengali, LDSS-5023 Chinese, LDSS-5023 Haitian Creole, LDSS-5023 Italian, LDSS-5023 Korean, LDSS-5023 Polish, LDSS-5023 Russian, LDSS-5023 Spanish, LDSS-5023 Yiddish

            Child Support Services

            • Acknowledgment of Parentage (LDSS-5171)
              • LDSS-5171 - Arabic, LDSS-5171 - Bengali, LDSS-5171 - Chinese, LDSS-5171 - French, LDSS-5171 - Haitian Creole, LDSS-5171 - Italian, LDSS-5171 - Korean, LDSS-5171 - Polish, LDSS-5171 - Russian, LDSS-5171 - Spanish, LDSS-5171 - Urdu, LDSS-5171 - Yiddish
              • LDSS-5258 - Arabic, LDSS-5258 - Bengali, LDSS-5258 - Chinese, LDSS-5258 - French, LDSS-5258 - Haitian Creole, LDSS-5258 - Italian, LDSS-5258 - Korean, LDSS-5258 - Polish, LDSS-5258 - Russian, LDSS-5258 - Spanish, LDSS-5258 - Urdu, LDSS-5258 - Yiddish
              • LDSS-5258A - Arabic, LDSS-5258A - Bengali, LDSS-5258A - Chinese, LDSS-5258A - French, LDSS-5258A - Haitian Creole, LDSS-5258A - Italian, LDSS-5258A - Korean, LDSS-5258A - Polish, LDSS-5258A - Russian, LDSS-5258A - Spanish, LDSS-5258A - Urdu, LDSS-5258A - Yiddish

              Temporary Assistance for Needy Families (TANF)

              • TANF Services Certification (LDSS-4726)
                • LDSS-4726 Arabic, LDSS-4726 Bengali, LDSS-4726 Chinese, LDSS-4726 French, LDSS-4726 Haitian Creole, LDSS-4726 Italian, LDSS-4726 Korean, LDSS-4726 Polish, LDSS-4726 Russian, LDSS-4726 Spanish, LDSS-4726 Urdu, LDSS-4726 Yiddish
                • LDSS-4770 Arabic, LDSS-4770 Bengali, LDSS-4770 Chinese, LDSS-4770 French, LDSS-4770 Haitian Creole, LDSS-4770 Italian, LDSS-4770 Korean, LDSS-4770 PolishLDSS-4770 Russian, LDSS-4770 Spanish, LDSS-4770 Urdu, LDSS-4770 Yiddish

                Application Booklets

                Information on your rights and responsibilities, and the services and programs available to you.

                • What You Should Know About Your Rights and Responsibilities (LDSS-4148A)
                  • LDSS-4148A Arabic, LDSS-4148A Bengali, LDSS-4148A Chinese, LDSS-4148A French, LDSS-4148A Haitian Creole, LDSS-4148A Italian, LDSS-4148A Korean, LDSS-4148A Polish, LDSS-4148A Russian, LDSS-4148A Spanish, LDSS-4148A Urdu, LDSS-4148A Yiddish
                  • LDSS-4148B Arabic, LDSS-4148B Bengali, LDSS-4148B Chinese, LDSS-4148B French, LDSS-4148B Haitian Creole, LDSS-4148B Italian, LDSS-4148B Korean, LDSS-4148B Polish, LDSS-4148B Russian, LDSS-4148B Spanish, LDSS-4148B Urdu, LDSS-4148B Yiddish
                  • LDSS-4148B.1 Arabic, LDSS-4148B.1 Bengali, LDSS-4148B.1 Chinese, LDSS-4148B.1 French, LDSS-4148B.1 Haitian Creole, LDSS-4148B.1 Italian, LDSS-4148B.1 Korean, LDSS-4148B.1 Polish, LDSS-4148B.1 Russian, LDSS-4148B.1 Spanish, LDSS-4148B.1 Urdu, LDSS-4148B.1 Yiddish
                  • LDSS-4148A and LDSS-4148B Supplement - Arabic, LDSS-4148A and LDSS-4148B Supplement - Bengali, LDSS-4148A and LDSS-4148B Supplement - Chinese, LDSS-4148A and LDSS-4148B Supplement - French, LDSS-4148A and LDSS-4148B Supplement - Haitian Creole, LDSS-4148A and LDSS-4148B Supplement - Italian, LDSS-4148A and LDSS-4148B Supplement - Korean, LDSS-4148A and LDSS-4148B Supplement - Polish, LDSS-4148A and LDSS-4148B Supplement - Russian, LDSS-4148A and LDSS-4148B Supplement - Spanish, LDSS-4148A and LDSS-4148B Supplement - Urdu, LDSS-4148A and LDSS-4148B Supplement - Yiddish
                  • LDSS-4148C Arabic, LDSS-4148C Bengali, LDSS-4148C Chinese, LDSS-4148C French, LDSS-4148C Haitian Creole, LDSS-4148C Italian, LDSS-4148C Korean, LDSS-4148C Polish, LDSS-4148C Russian, LDSS-4148C Spanish, LDSS-4148C Urdu, LDSS-4148C Yiddish
                  • LDSS-5084 Arabic, LDSS-5084 Chinese, LDSS-5084 Haitian Creole, LDSS-5084 Italian, LDSS-5084 Korean, LDSS-5084 Russian, LDSS-5084 Spanish

                  What are my Rights?

                  • What Are My Rights? (LDSS-5208)
                    • LDSS-5208 Arabic, LDSS-5208 Bengali, LDSS-5208 Chinese, LDSS-5208 French, LDSS-5208 Haitian Creole, LDSS-5208 Italian, LDSS-5208 Korean, LDSS-5208 Polish, LDSS-5208 Russian, LDSS-5208 Spanish, LDSS-5208 Urdu, LDSS-5208 Yiddish

                    This page contains links to PDF documents. Download Acrobat Reader to view these documents.

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