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Social Services Forms

Form Description Pages

Directory for Public Access to Social Services Programs

Spanish Version

Directory for Public Access to Social Services Programs. Telephone directory and available services. 14

WebFraudReportingForm.pdf

Spanish Version

If you believe an individual has received welfare assistance improperly, please take the time to share this information with us. 1

FOIL Request

Spanish Version

Application for Public Access to Records 2

Child Care Services
Form Description Pages

OCFS-6025 Application for Child Care

OCFS-6025-S Spanish Version

This application may be used if your family is ONLY applying for child care services. If your family is applying for public assistance or other benefits including child care services, you MUST use the Statewide Common Application (LDSS-2921), which can be found in the State Forms section below. 2

OCFS-6026 Instructions

OCFS-6026-S Spanish Version

How to complete the OCFS-6025 Application for Child Care Assistance 4

CCB-6010-018 Documentation Required for Child Care Eligibility

CCB-6010-018 Spanish Version

List of the types of documentation you can submit as proof of identity, address, legal residence in U.S., income, etc. 2

CCB-6010-002 Verification of Residence

CCB-6010-002 Spanish Version

Have your landlord or other professional person who knows you and your family complete this form verifying your residency and household composition. 1

CCB-6010-003 Absent Parent Information Form

CCB-6010-003 Spanish Version

Only complete this form if the parent(s) of any child(ren) in need of child care is(are) NOT in the household. Fill out a separate section for EACH parent that is absent from the household. Attach additional pages if needed. 2

CCB-6010-004 Confidential Inquiry on Employment

CCB-6010-004 Spanish Version

Each parent who is working must have their employer complete this form (OR submit a written statement) verifying the days & hours usually worked and wages earned. If you are working more than one job, a separate form (or written statement) must be completed for each job. Twelve (12) weeks of pay stubs must also be submitted. 1

CCB-6010-005 Self-Employment Worksheet

CCB-6010-005 Spanish Version

Submit this form if you are self-employed. You must also submit the required supporting documentation (see reverse side of the Self-Employment Worksheet). 2

CCB-6010-006 School/Vocational Training Verification Form

CCB-6010-006 Spanish Version

If your reason for needing child care is school or Vocational training attendance, have the school/program complete this form documenting your attendance. NOTE: You must also be working at least 17.5 hours per week and earning at least minimum wage to qualify for a child care subsidy. EXCEPTION: Teen parents attending High School are NOT required to be employed. 1

CCB-6010-007 Child Care Provider Information Sheet

CCB-6010-007 Spanish Version

Use this form to identify the child(ren) in need of a child care subsidy, what days/hours child care is needed, and whether the child(ren) is(are) already in child care or you need to locate a child care provider for your child(ren). 1

CCB-6010-009 Client Responsibility Notice

CCB-6010-009 Spanish Version

You are required to read, sign and return this notice acknowledging your responsibility to immediately report to DSS any changes to your employment, income, housing, household composition, child care provider, etc. 1

CCB-6010-010 Medical Statement in Support of Special Needs Consideration & Definition of Child with Special Needs in Need of Child Care

CCB-6010-010 Spanish Version

Have a qualified professional complete this form for each child in need of a child care subsidy who has a diagnosed special need that adversely affects the child's ability to function normally. Refer to the "Definition of Child with Special Needs in Need of Child Care" that is attached to the form. 3

CCB-6010-016 Employer Statement

CCB-6010-016 Spanish Version

Employee Earnings Paid in Cash form for Employer. 1

CCB-6010-019 Special Needs Rate Application

CCB-6010-019 Spanish Version

Application for additional funding for a special needs child. 3

Client Benefit Services
Form Description Pages
Housing Package Forms (English and Spanish) Housing Package Forms for Tenant, Broker, Landlord. 15

Hospital Homeless Discharge Referral Form

Spanish Version

For Hospitals and Medical Facilities only 3
Reimbursable Cost Manual for Not-For-Profit Shelters This manual explains what costs the County of Suffolk will accept and not accept for reimbursement under the Emergency Homeless Shelter Program. (revised August 2016). 32

LDSS4530 Assignment of Wages with Local Address

Spanish Version

Assignment of Wages Local Address 3

SCO 221 Housing Verification Rev. 5-08

Spanish Version

Housing Verification 2
SCO 2232-C Consent for Verification of Info (Contains both English and Spanish) Consent for Verification of Info 1

SCO 227 Verification of school attendance

Spanish Version

Verification of school attendance 1

SCO 2395 Shelter Supplement Application

Spanish Version

SSP Application. 3

SCO 2565 Shelter Arrears Breakdown

Spanish Version

Shelter Arrears Breakdown 1

SCO IM 206 Confidential Employment Inquiry

Spanish Version

Confidential Employment Inquiry 2

Medicaid Services
Form Description Pages

DOH-4287 NOA Continuing your MED-FHP

Spanish Version

Continuing your Medicaid or Family Health Plus Benefits 11

DOH-4443 Financial Maintenance

Spanish Version

Financial Maintenance form for listing monthly expenses 1

DOH-5017 Verification Of Employment OHIP

Spanish Version

Verification of Employment 1

DOH-5018 Self Declaration Of Income OHIP

Spanish Version

Self-Declaration of Income 1

New York State Forms

Form Description Pages

LDSS-2921: Application for Public Assistance - Medical Assistance - SNAP - Services

Spanish Version

Common Instrument that must be completed by applicants for programs administered by NY State Family and Children Services and the NY State Department of Health. 18

Pub-1301 How To Complete the Social Services Application

Spanish Version

Companion Instructions to the DSS 2921 10

LDSS-4148A

LDSS-4148A Spanish Version

What You Should Know About Your Rights and Responsibilities (when applying for or receiving benefits). 36

LDSS-4148B

LDSS-4148B Spanish Version

What You Should Know About Social Services Programs- Q & A. 44

LDSS-4148C

LDSS-4148C Spanish Version

What You Should Know If You Have An Emergency 8

Medicaid/DOH
Form Description Pages

DOH-4220 Access New York Health Care Application

DOH-4220 Spanish Version

This application is to be used to apply for Children's Medicaid, Child Health Plus, Family Health Plus, Medicaid, Prenatal Care Assistance Program (PCAP), and Women, Infants and Children (WIC) nutritional programs. Based upon the information you provide, you will be told which program you and/or your child(ren) are eligible for. In addition to the Medicaid application DOH-4220, Access NY Supplement A is required for persons applying for Medicaid who are disabled or age 65 or older in receipt of Nursing Home care. 17

DOH-4282 Family Planning Benefit Program Application

DOH-4282 Spanish Version

This application is to be completed for the Family Planning Benefit Program (FPBP). FPBP is a program for New Yorkers who need family planning services, but may not be able to afford them. It is intended to increase access to family planning services and to enable individuals of childbearing age to prevent or reduce the incidence of unintentional pregnancies. 2

DOH-4328 Medicare Savings Program Application

DOH-4328 Spanish Version

This application is to be completed when applying for Medicare Savings Program (MSP) only – not Medicaid. The MSP program pays the Medicare Part B premium and, for eligible individuals, the coinsurance and deductible payments. 2

DOH-5178A - Supplement to Access NY Health Care Application

DOH-5178A - Spanish version

If the applicant is disabled, age 65 or older, or in receipt of Nursing Home care. The Supplement A must be completed.
Note: If you are applying for the Medicare Savings Program (MSP) only, this Supplement does not need to be completed.
8

Child Support Enforcement Bureau
Form Description Pages

LDSS-4882: Information about Child Support Services

Spanish Version

What you should know about Child Support Services and Application/Referral for Child Support Services. 16

Client Benefit Services
Form Description Pages
LDSS-2291 – Request for Replacement of Food Purchased with Supplemental Nutrition Assistance Program (SNAP) Benefits (contains both English and Spanish versions) SNAP clients utilize this form if SNAP food is destroyed due to natural event or other disaster. 2

LDSS-3151 – Supplemental Nutrition Assistance Program (SNAP) Change Report Form

LDSS-3151 Spanish Version

SNAP clients utilize this form to report any changes required under the rules. 6

LDSS-3174 – New York State Recertification Form for Certain Benefits and Services

LDSS-3174 Spanish Version

Common Instrument completed by clients to recertify for Public Assistance, Supplemental Nutrition Assistance Program (SNAP), Medicaid and SNAP, and Medicaid and Public Assistance. 26

PUB-1313 – Instructions for Completing the New York State Recertification Form for Certain Benefits and Services

PUB-1313 Spanish Version

Companion Instructions to the LDSS-3174 20

LDSS-4826: SNAP Benefits Application

LDSS-4826 Spanish Version

This application can only be used to apply for Supplemental Nutrition Assistance Program (SNAP) Benefits. 12

LDSS-4826A – How to Complete the Supplemental Nutrition Assistance Program (SNAP) Application/Recertification and Applicant/Recipient Rights and Responsibilities for SNAP

LDSS-4826A Spanish Version

Companion Instructions to the LDSS-4826 11

LDSS-4942 – SNAP Authorized Representative Request Form

LDSS-4942 Spanish Version

Clients utilize this form to authorize someone to apply for SNAP benefits for them and/or authorize someone to use their SNAP benefit card to buy food for them. 2

Suffolk County Government

H. Lee Dennison Bldg

100 Veterans Memorial Hwy
P.O. Box 6100
Hauppauge, NY 11788

Riverhead County Center

County Road 51
Riverhead, NY 11901