Fillable LDSS-4826 DD(Rev. 2/18) (monroe county)

Fill Online, Printable, Fillable, Blank LDSS-4826 DD(Rev. 2/18) (monroe county) Form

Use Fill to complete blank online MONROE COUNTY (NY) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LDSS-4826 DD(Rev. 2/18) (monroe county)

On average this form takes 98 minutes to complete

The LDSS-4826 DD(Rev. 2/18) (monroe county) form is 17 pages long and contains:

  • 0 signatures
  • 75 check-boxes
  • 355 other fields

Country of origin: US
File type: PDF

U.S.A. forms for monroe county

BROWSE MONROE COUNTY (NY) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
LDSS-4826 DD(Rev. 2/18)
NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
(SNAP) APPLICATION/RECERTIFICATION
This application can ONLY be used to apply for SNAP
If you are blind or seriously visually impaired and need this application in an alternative format, you may
request one from your social services district. For additional information regarding the types of formats
available and how you can request an application in an alternative format, see the instruction book
(LDSS-4826A), or
www.otda.ny.gov
.
____ ____
___ ___ ___
___
If you are blind or seriously visually impaired, would you like to receive written notices in an alternative
format?
Yes No
If Yes, check the type
of format you would like: Large Print Data CD Audio CD
Braille, if you assert that none of the other alternative formats will be eq ually effective for you
.
If you require another acco mmodation, please contact your social services district.
If you are only applying for SNAP you can use this shorter application. If you would like to apply for other benefits such as Temporary Assistance, Child Care Assistance, Home
Energy Assistance or Medicaid please ask for a different application.
When You Are Applying For SNAP
•
You can file an application the same day you receive it. We must accept your application if, at a minimum, it contains your name, address, (if you have one), and a signature. This information
will establish your application filing date.
• You must complete the application process, including having an interview and signing the certification statement on page 8 of the application/recertification for your eligibility to be determined.
If you are eligible, benefits will be provided back to the date you filed your application.
• You can apply for and get SNAP for eligible household member(s) even if you or some other members of your household are not eligible for benefits because of immigration status. For
example, ineligible alien parents can apply for SNAP for their children and receive benefits for their eligible children.
• You can still apply and be eligible for SNAP even if you have reached your Temporary Assistance time limits.
LDSS-4826 DD (Rev. 2/18) Page 1
Need SNAP Benefits Right Away? You May Be Eligible For Expedited Processing of your SNAP Application:
If your household has little or no income or liquid resources, or if your rent and utility expenses are more than your income and liquid resources, or you are a migrant or seasonal
farmworker with little or no income or resources when you apply, you may be eligible to get SNAP within 5 calendar days of the date you apply. When a resident of an institution is
jointly applying for SSI and SNAP prior to leaving the institution, the recorded filing date of the application is the date of release of the applicant from the institution.
Where You Can Apply For SNAP
If you live outside of New York City, you can apply on-line at
myBenefits.ny.gov
, or call or visit the social services district in the county where you live and ask for an application
package, which can be mailed or dropped off to that appropriate office. You can get the address and phone number of the social services district in your county by calling toll free 1-
800-342-3009.
If you live in New York City and you are not also applying for Temporary Assistance, you can apply on-line at
myBenefits.ny.gov
, or call or visit any SNAP Office and ask for an
application package. You can get the address and phone number by calling 1-718-557-1399 or toll free 1-800-342-3009.
Having Problems Coming To Us For A SNAP Interview Appointment?
If it is difficult for you to come in for a SNAP interview appointment (reasons may include employment, health issues, transportation or child care problems), in some circumstances;
we can interview you by telephone, or you may have someone else apply for you. Please contact your social services district if you have any questions, to see if you are eligible for
a telephone interview, or if you need to reschedule an interview.
NON-DISCRIMINATION NOTICE – In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies,
offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed,
disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audio tape, American Sign Language, etc.), should contact the
Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800)
877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html
,
and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-
9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)
fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
LDSS-4826 DD (Rev. 2/18) Page 2
NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE
SNAP APPLICATION / RECERTIFICATION
Application Date Interview Date Center/Office Unit Worker Case Type Case Number
Registry Number Version
Apply Recertify
_______________________________________________ __________________________ ________________________
__________________________________________________________________________ ____ ___________________________ ________________
____________________________________________________________________ ____ ___________________________ ________________
________________________________
Lang
Legal Name: Telephone Number: Other phone where you can be reached:
Residence Address: Apt.# City , NY Zip Code
Mailing Address (if different) Apt.# City , NY Zip Code
Known by Any Other Name: Are You:
Applying or Recertifying Do you want to receive notices in: Spanish and English or English Only
We must accept your application if, at a minimum, it contains your name,
address (if you have one), and signature in this box.
APPLICANT/REPRESENTATIVE SIGNATURE DATE SIGNED
List everyone who lives with you even if they are not applying. List yourself first.
L
N
First Name
M
I
Last Name
Social Security Number
(SSN) of applying member
(If none, write “NONE”)
Date of Birth
Marital
Status
Sex
M
or
F
Is this person
applying?
Yes
No
Relationship
to you
Do you buy
and/
or prepare
food with this
person?
Yes
No
Hispanic
or
Latino?
Yes
No
Enter Y (Yes) or N (No) for each
race*
(Codes Defined Below)
I
A
B
P
W
1
✓
self
✓
2
3
4
5
6
7
8
*Race/Ethnic Codes: I – Native American or Alaskan Native, A - Asian, B – Black or African American, P – Native Hawaiian or Pacific Islander, W – White
The provision of this information is voluntary. It will not affect the eligibility of the persons applying or the level of benefits received. The reason for this information is to ensure that program benefits are
distributed without regard to race, color or national origin.
Are you and is everyone living with you a US citizen? Yes
No If No, who is not a citizen?
Are you or is anyone in your household applying for or receiving SNAP or Temporary Assistance in another place? Yes No
Are you or is anyone living with you a veteran? Yes No If Yes, who
Do you or does anyone live in a drug or alcohol treatment center, State-certified group living facility or State-certified supervised/supportive apartment?
Yes No
If you are recertifying for SNAP, list on Page 9 what has changed since your last application or recertification (such as moved, had a baby, someone moved in or out of your household).
You may use page 9 if you need more room or there is other information that you think we might need. Go to Page 3
LDSS-4826 DD (Rev. 2/18) Page 3
INCOME
List ALL your income and the income of everyone living with you. This includes, but is not limited to wages, income from self-employment minus the cost of producing self-employment (for
example: babysitting, cleaning, income from a roomer or boarder), child support, pensions, veteran’s benefits, disability, social security or SSI, grants or scholarships for rent or
food, Temporary Assistance, and income from friends or relatives.
Name of Person Receiving Income
Source of Income
Hours Worked Per Month
How Often is it Received?
(for example, weekly, bi-weekly,
monthly)
Gross Amount Received
Before Deductions
Do you or does anyone living with you have child/dependent care costs related to employment or training? Yes No If Yes, who
Amount paid $
.
____________. _________________________.
How often paid (e.g., weekly, monthly)
Have you or has anyone living with you changed or quit jobs or reduced any form of income in the last 30 days – including reduced work hours or income? Yes No
Do you or does anyone living with you have any potential income that has not yet been received? Yes No If Yes, explain on Page 9.
Are you or is anyone living with you participating in a strike?
Yes No If Yes, who
_________________________________________________________ .
Are you or is anyone living with you a boarder, foster child, or foster adult? Yes No
If Yes, check B for boarder or F for foster and write their name.
B .
______________ .
_______________ ________________________________ _________________________________.
___ _____ _______________________ ________________________ _________________________
F Name:
RESOURCES
Resources do not affect the eligibility of most households applying for SNAP. However, some resource information is used to determine if you qualify for expedited processing of your application.
How much money does everyone in your household have? (For example, on your person; in your home, in checking and savings accounts, or other locations, including jointly held accounts)
$ Belongs to
Other financial assets? (For example, stocks, bonds, retirement accounts, savings bonds, mutual funds, IRAs, trust funds, money market certificates) Yes
No
If Yes, amount $ Type Owner
How many cars, trucks or other vehicles do you or anyone in your household have?
#1 Year Make Model Owner
___ _____ _______________________ ________________________ _________________________
#2 Year Make Model Owner
Do you or anyone applying own any property including your own home? Yes
_______________________________ ________________________
No If yes, list property Owner
Has anyone applying sold, given away or transferred cash or property in the last three months to qualify for SNAP? Yes No
LDSS-4826 DD (Rev. 2/18) Page 4
EDUCATION/TRAINING AND LANGUAGE
Enter the name of each applying person in the household aged 16 or older, including yourself. For each person, put an “X” in the box in the “Highest Level of Education” section, using the
education and training codes shown below. Check only one box per person. If you enter an “X” in the “0” column for a person, (indicating they do not have a high school diploma or a high school
equivalency diploma), enter their highest school grade completed in the “Highest School Grade Completed” box (example – if a person is in 10
th
grade, put “9” in the “Highest School Grade
Completed” box). Leave the “Highest School Grade Completed” box blank if the “0” column is not checked for a person in high school or obtaining a high school equivalency diploma.
Additionally, please identify the primary language spoken for each individual in the SNAP household that is age 16 or older. The primary language is the language the individual speaks most often.
Name (First and Last)
Highest Level of Education*
(Codes Defined Below)
0
1
2
3
4
5
8
Highest School Grade
Completed
(see information below)
What is the Individual’s primary
language spoken?
* Education and Training Codes: 0 – Less than a high school diploma or equivalency; 1 – High school diploma or high school equivalency diploma; 2 – Associates Degree (2-year college
degree); 3 – Bachelor’s degree (4-year college degree); 4 – Graduate degree (Master’s or higher); 5 – Completion of an Individualized Education Plan (IEP); 8 – Unknown
NOTE: The provision of information regarding highest level of education, highest school grade and primary language spoken is voluntary. It will not affect the eligibility of the persons applying
or the level of benefits received. The reason for this information is to meet federal reporting requirements.
LIVING ARRANGEMENTS AND EXPENSES
Check all the descriptions that apply to your household:
Own home or paying for home
Renting Migrant/seasonal farmworker No permanent residence Live with relatives or friends
List expenses:
Monthly rent or mortgage payment $
____________________ _______________________ _____________________.
_______________
___________________________ ______________________________
Tax on home per year $ Insurance on home per year $
Pay separately for Heat? Yes No If yes, specify type of heating: Gas Electric Oil Wood Coal Propane Other (list)
Heat Co. Name Heat Co. Acct. No.
________________________________________________________________________________ .
_____________________________________
______________________________________________________________________________________________
_______________ _______________
_____________________________________
Pay for air conditioning, either in your electric bill or as a separate fee? Yes No
Pay separately for utilities (other than heating/cooling)? Yes No (for example, lights, cooking gas, garbage/trash, water, initial installation of utilities).
Does anyone else pay any of these expenses for you (some examples are Section 8 or other subsidy program)?
Yes No If yes, who pays what?
Are you or is anyone living with you paying legally obligated child support? Yes No If yes, who
Name(s) of child(ren) support is being paid for
Payment amount $ Frequency of payments (for example, weekly, bi
-weekl
y, monthly)
Are you, and/or anyone living with you, disabled or at least age 60? Yes No If yes, who
If so, does such person have medical bills? Yes No
If yes, list on page 9 what they are for, how much and who is responsible for payment.
LDSS-4826 DD (Rev. 2/18) Page 5
LIVING ARRANGEMENTS AND EXPENSES (cont’d)
Are you, and/or anyone living with you, on Medicaid with a spenddown? Yes No If yes, who Amount $
_____________________________________ ______________________
Are you or anyone living with you (16 or 17 years of age) enrolled in school or training?
Yes
_________________________ ________
__________________
_________________________________________
No If yes, who Name of School/Training Program
Are you or anyone living with you, between the ages of 18 and 49 years of age, attending a school or training program (above High School)?
Yes No If yes, who?
Name of School/Training program
Full Time (FT) Yes No
______________________________________________
___________________________________________
Income Yes No Expenses Yes No
Are there adults in the household age 16 and older (including the applicant) who:
Are pregnant? Yes No If yes, who
Have any medical conditions that limit their ability to work or the type of work that they can perform? Yes No If yes, who
Answer these questions:
Are you or is anyone living with you violating a condition of probation or parole or fleeing to avoid prosecution, custody or confinement for a felony and actively being pursued by law enforcement?
Yes
___________________________
_________________________________________
_______________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
No If yes, who
Are you or is anyone living with you in violation of probation o
r parole according to a court? Yes No If yes, who
Have you or has anyone living with you ever been disqualified from receiving SNAP because of fraud or intentional program violation? Yes
No If yes, who
Have you or has anyone living with you been convicted of trading SNAP benefits for firearms, ammunition or explosives, or drugs after Septe
mber 22, 1996? Yes No
If yes, who
Have you or has anyone living with you been convicted of buying or selling SNAP benefits for a combined amount of $500 or more, after September 22, 1996? Yes
No
If yes, who
Have you or has anyone living with you been convicted of fraudulently receiving duplicate SNAP benefits in any State after September 22, 1996?
Yes No
If yes, who
You may use page 9 if you need more room or there is other information that you think we might need.
READ THE IMPORTANT INFORMATION BELOW
SNAP PENALTY WARNING – Any information you provide in connection with your application for SNAP will be subject to verification by Federal, State and local officials. If any information is
incorrect, you may be denied SNAP. You may be subject to criminal prosecution if you knowingly provide incorrect information which affects eligibility or the amount of benefits. Anyone
who is violating a condition of probation or parole or anyone who is fleeing to avoid prosecution, custody or confinement for a felony, and is actively being pursued by law enforcement, is
not eligible to receive SNAP benefits.
If a SNAP household member is found to have committed an Intentional Program Violation (IPV), the member will not be able to get SNAP benefits for a period 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 SNAP benefits in a transaction involving the sale of a controlled substance. (Illegal
drugs or certain drugs for which a doctor’s prescription is required.)
• 120 months if found guilty of making a false statement about who you are or where you live in order to get multiple SNAP benefits simultaneously, unless permanently disqualified for a
third IPV.
Additionally, a court may bar an individual from participation in SNAP for an additional 18 months.
LDSS-4826 DD (Rev. 2/18) Page 6
READ THE IMPORTANT INFORMATION BELOW (cont’d)
Permanent disqualification of an individual for:
• The first SNAP-IPV based on a court finding of using or receiving SNAP benefits in a transaction involving the sale of firearms, ammunition or explosives.
• The first SNAP-IPV based on a court conviction for trafficking SNAP benefits for a combined amount of $500 or more (Trafficking includes the illegal use, transfer, acquisition, alteration
or possession of SNAP authorization cards or access devices.)
• The second SNAP-IPV based on a court finding that an individual used or received SNAP benefits in a transaction involving the sale of controlled substances. (Illegal drugs or certain
drugs for which a doctor’s prescription is required.)
• All third SNAP-IPV Intentional Program Violations.
Any person convicted of a felony for knowingly using, transferring, acquiring, altering or possessing SNAP authorization cards or access devices may be fined up to $250,000, imprisoned up
to 20 years or both. The individual may also be subject to prosecution under the applicable Federal and State laws.
You may be found ineligible for SNAP or found to have committed an IPV if:
• You make a false or misleading statement, or misrepresent, conceal or withhold facts in order to qualify for benefits or receive more benefits; or
• Purchase a product with SNAP benefits with the intent of obtaining cash by intentionally discarding the product and returning the container for the deposit amount; or
• Commit or attempt to commit an act that constitutes a violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of
SNAP benefits, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system.
Additionally, the following is not allowed and, you may be disqualified from receiving SNAP benefits and/or be subject to penalties for actions that include:
• Using or have in your possession EBT cards that do not belong to you, without the card owner’s consent; or
• Using SNAP benefits to buy nonfood items, such as alcohol or cigarettes, or to pay for food previously purchased on credit; or
• Allowing someone else to use your electronic benefit transfer (EBT) card in exchange for cash, firearms, ammunition, explosives or drugs, or to purchase food for individuals who are not
members of the SNAP household.
If you get more SNAP benefits than you should have (overpayment), you must pay them back. If your case is active, we will take back the amount of the overpayment from future SNAP benefits that you
get. If your case is closed, you may pay back the overpayment through any unused SNAP benefits remaining in your account, or you may pay by cash.
If you have an overpayment that is not paid back, it will be referred for collection, including automated collection by the federal government. Federal benefits (such as Social Security) and tax refunds that
you are entitled to receive may be taken to pay back the overpayment. The debt will also be subject to processing charges.
Any SNAP benefits expunged from your EBT account will be used to reduce current overpayments. If you apply for SNAP again, and have not repaid the amount you owe, your SNAP benefits will be
reduced if you begin to get them again. You will be notified, at that time, of the amount of reduced benefits you will get.
CONSENT – I understand that by signing this application form I agree to any investigation made by the New York State Office of Temporary and Disability Assistance or my local social services
district to verify or confirm the information I have given or any other investigation made by them in connection with my request for SNAP benefits. If additional information is requested, I will provide
it. I will also cooperate with State and Federal personnel in a SNAP Quality Control Review.
I understand that by signing this application/certification, I consent to an investigation to verify or confirm the information I have given and other investigation by any authorized government agency
in connection with Home Energy Assistance Program (HEAP) benefits. I also consent to allow the information provided on this application to be used in referrals to available weatherization
assistance programs and my utility company’s low income programs. I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP.
This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my annual electricity
usage, electricity cost, fuel consumption, fuel type, annual fuel cost and payment history to the Office of Temporary and Disability Assistance and the local Social Services District and the United
States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program (LIHEAP) performance measurement.
CONSENT FOR RELEASE OF CONFIDENTIAL UNEMPLOYMENT INSURANCE (UI) INFORMATION – I authorize the New York State Department of Labor (DOL) to release any confidential
information, maintained by DOL for Unemployment Insurance (UI) purposes, to the New York State Office of Temporary and Disability Assistance (OTDA). This information includes UI benefit
claims and wage records. I understand that OTDA, along with State and local agency employees working in local social services district offices, will use the UI information for establishing or
verifying eligibility for, and the amount of SNAP applied for in this application and for investigations to determine whether I received benefits to which I was not entitled.
LDSS-4826 DD (Rev. 2/18) Page 7
READ THE IMPORTANT INFORMATION BELOW (cont’d)
RELEASE OF INFORMATION TO SERVICE PROVIDERS - I give permission to the social services district and New York State to share information regarding Supplemental Nutrition Assistance
Program benefits that I or any member of my household for whom I can legally give authorization have received, for purposes of verifying my eligibility for services and payment related to program
administration provided by a State or local contractor. Such services may include, but are not limited to, job placement or training services provided to help me or my household members obtain
and retain employment.
SUA (STANDARD UTILITY ALLOWANCE) INFORMATION – I understand that SNAP recipients are categorically income eligible for the Home Energy Assistance Program (HEAP). If I have not
received a HEAP benefit of greater than $20 in the current month or previous 12 months, or other similar energy assistance program benefits, I must pay separately for a heating, air conditioning
or utility expense in order to receive a Standard Utility Allowance.
CHANGES – I agree to inform the agency promptly of any change in my needs, income, property, living arrangement, able-bodied adult without dependents (ABAWD) status including if my hours
of work fall below 80 hours per month, pregnancy status or address to the best of my knowledge or belief in accordance with my reporting requirements.
REQUIREMENT TO REPORT/VERIFY HOUSEHOLD EXPENSES – I understand that my household must report child care and utility expenses in order to get a SNAP deduction for these
expenses. I further understand that my household must report and verify rent/mortgage payments, property taxes, insurance, medical expenses and child support paid to a non-household member
in order to get a SNAP deduction for these expenses. I understand that failure to report/verify the above expenses will be seen as a statement by my household that I/we do not want to receive a
deduction for those unreported/unverified expenses. A deduction for these expenses may make me eligible for SNAP or may increase my SNAP benefits. I understand that I may report/verify
these expenses at any time in the future. This deduction would then be applied to the calculation of SNAP in future months in accordance with the rules for change reporting and processing
changes.
In applying for SNAP, I understand that the social services district will request and use information available through the Income and Eligibility Verification System to investigate my application, and
may verify this information through collateral contacts if discrepancies are found. I also understand that such information may affect my eligibility for SNAP and/or level of SNAP benefits I receive.
PRIVACY ACT STATEMENT – COLLECTION AND USE OF SOCIAL SECURITY NUMBER (SSN) – The collection of SSN’s is authorized for each household member with respect to SNAP
pursuant to the Food and Nutrition Act of 2008. The information we collect will be used to determine whether your household is eligible or continues to be eligible for assistance or benefits. We will
verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. This information
may be disclosed to other State and Federal agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. The information
will be used to check identity and to verify earned and unearned income.
If a SNAP claim arises against your household, the information on this application, including all SSN’s, may be referred to Federal and State agencies, as well as private claims collection agencies,
for claims collection action. Anyone applying for SNAP must provide a SSN. SSN’s of ineligible members will also be used and disclosed in the manner above. If you or anyone
applying/recertifying does not have a SSN, a SSN must be applied for with the Social Security Administration (SSA.gov).
Besides using the information, you give us in this way, the State also uses the information to prepare statistics about all the people receiving benefits from the Home Energy Assistance Program.
The information is used for quality control by the State to make sure local districts are doing the best job they can. It is used to verify who your energy supplier is and to make certain payments to
such vendors.
CITIZENSHIP/IMMIGRATION STATUS– I swear and/or affirm under penalty of perjury that the information I have provided about the citizenship and immigration status of myself and everyone
living with me is true and correct. I understand that any information I provide to verify the immigration status of anyone applying for SNAP may be checked for authenticity with the United States
Citizenship and Immigration Services.
For SNAP, citizenship must be documented only if questionable.
LDSS-4826 DD (Rev. 2/18) Page 8
READ THE IMPORTANT INFORMATION BELOW (cont’d)
AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to apply for SNAP for you. You can also authorize someone outside your household
to get SNAP benefits for you and to use them to buy food for you. If you would like to authorize someone, you must do so in writing. You may do so by printing the person’s name, address and
phone number below. When an Authorized Representative is applying on behalf of a SNAP household that does not reside in an institution, both the Authorized Representative and a responsible
adult member of the SNAP household must sign and date the signature sections at the bottom of this page, unless the Authorized Representative has been otherwise designated by the household
in writing.
IF YOU WOULD LIKE TO AUTHORIZE SOMEONE, PRINT THE PERSON’S NAME, ADDRESS AND TELEPHONE NUMBER, AND SIGN BELOW.
Name Address ______________________________________________ ____________________________________________________ _______________
_______________________________________________ ____________________________________________________ _______________
Phone
CERTIFICATION: I swear and/or affirm under the penalties of perjury that the information I have given or will give to the local Social Services district is correct.
Your signature is required below to complete the application process.
APPLICANT SIGNATURE (or Responsible Adult Household Member)
X
DATE SIGNED
Authorized Representative SIGNATURE
X
DATE SIGNED
IF YOU HELPED COMPLETE THIS APPLICATION / RECERTIFICATION FOR SOMEONE ELSE, PRINT YOUR NAME AND ADDRESS HERE. YOU MAY ALSO
VOLUNTARILY PRINT YOUR TELEPHONE NUMBER.
Name Address Phone
LDSS-4826 DD (Rev. 2/18) Page 9
Use this area for additional information:
Who:
________________________________________
________________________________________
________________________________________
____________________________________________________________
Explanation:
Who: Explanation:
Who: Explanation:
I CONSENT TO WITHDRAW MY APPLICATION/RECERTIFICATION. I understand that I may reapply at any time.
SIGNATURE DATE
For Agency Use Only
Eligibility Determined by Date
___________________
________________________________________ _______________
_____/_____/______
______________________________________________________________ __________________
______________________ ______________________
Signature of Person Who Obtained Eligibility Information: Date
Reason Withdrawal Denial Recert. Closing
Eligibility Approved by Date
SNAP Authorization Period: From To
IN-PERSON INTERVIEW TELEPHONE INTERVIEW
Comments:
NYS Agency-Based Voter Registration Form
“If you are not registered to vote where you live now, would you
like to apply to register here today?”
YES
NO because I choose not to register OR
I am already registered at my current address OR
I asked for and received a mail registration form
If you checked YES, please complete the
VOTER REGISTRATION APPLICATION below
If you do not check
any box, you will
be considered to
have decided not
to register to vote
at this time.
Signature Date
Please Print Name
/ /
Important!
Applying to register or declining to register to vote will not affect the
amount of assistance that you will be provided by this agency.
If you would like helplling out the voter registration application form,
we will help you. The decision whether to seek or accept help is yours.
You may ll out the application form in private.
Información en español: si le interesa obtener este formulario en español,
llame al 1-800-367-8683
中文資料:若您有興趣索取中文資料表格,請電: 1-800-367-8683
한국어: 한국어 한국어 양식을 원하시면 1-800-367-8683
으로 전화 하십시오.
 1-800-367-8683

Rev. 2 /2015
VOTER REGISTRATION APPLICATION (instructions on back)
Yes, I need an application for an Absentee Ballot Please print or type in blue or black ink Yes, I would like to be an Election Day worker
1
Are you a U.S. citizen?
If you answered NO, do not complete this form
YES NO
2
Will you be 18 years old on or before election day?
If you answered NO, do not complete this form
unless you will be 18 by the end of the year
YES NO
For Board Use Only
3
Last Name First Name Middle Initial Suf x
4
Address where you live (do not give P.O. box) Apt. No. City/Town/ Village Zip Code County
5
Address where you get your mail (if different than above) P.O. Box, Star Route, etc. Post Ofce Zip Code
6
Date of Birth
7
Sex
M F
8
Telephone (optional) Email (optional)
10
The last year you voted Your address was (give house number, street and city)
9
ID Number
(Check the applicable box and provide your number)
New York State DMV number
Last four digits of your Social Security number
I do not have a New York State DMV or Social Security number
In county/state Under the name (if different from your name now)
11
Democratic party
Republican party
Conservative party
Green party
Working Families party
Independence party
Women’s Equality party
Reform party
Other
Political Party
I wish to enroll in a political party
I do not wish to enroll in a political party
No party
12
Afdavit: I swear or afrm that
• I am a citizen of the United States.
• I will have lived in the county, city or village for at least 30 days before
the election.
• I will meet all requirements to register to vote in New York State.
• This is my signature or mark on the line below.
• The above information is true, I understand that if it is not true, I can be
convicted andned up to $5,000 and/or jailed for up to four years.
Signature or Mark in ink Date
/ /
Last Name
First Name Middle Initial Sufx
Address
Apt Number
City/ Town/Village Zip Code
Birth Date Sex
M F
Eye Color Height
Ft. In.
(Optional) Register to donate your organs and tissues
By signing below, you certify that you are:
• 18 years of age or older
• - Consent to donate all of your organs and tissues for
transplantation, research, or both;
• - Authorizing the Board of Elections to provide your name and
identif ying information to DOH for enrollment in the Registry;
• And authorizing DOH to allow access to this information to federally regulated organ
procurement organizations and NYS-licensed tissue and eye banks and hospitals
upon your death.
/ /
Signature
Date
Qualifications for Registration
You Can Use This Form To:
• register to vote in New York State;
• change your name and/or address, if there is a change since you
last voted;
• enroll in a political party or change your enrollment.
To Register You Must:
• be a U.S. citizen;
• be 18 years old by December 31 of the year in which you file this form
(note: You must be 18 years old by the date of the general, primary, or
other election in which you want to vote.);
• be a resident of the County, or of the City of New York at least 30 days
before an election;
• not be in jail or on parole for a felony conviction; and
• not claim the right to vote elsewhere.
Important!
If you believe that someone has interfered with your right to register or
to decline to register to vote, your right to privacy in deciding whether to
register or in applying to register to vote, or your right to choose your own
political party or other political preference, you may file a complaint with:
NYS Board of Elections
40 North Pearl St, Suite 5
Albany, NY 12207-2729
Telephone: 1-800-469-6872;
TDD/TTY users contact the New York State Relay at 711;
or visit our web site - www.elections.ny.gov
Your decision to register will remain confidential and will be used only for
voter registration purposes. Anyone not choosing to register to vote and/
or information regarding the office to which the application was submitted
will remain confidential, to be used only for voter registration purposes.
Verifying your identity
We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID
number), or the last four digits of your social security number, which you will fill in Box 9.
If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement,
paycheck, government check or some other government document that shows your name and address. You may include
a copy of one of those types of ID with this form.
If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.
To complete this form:
It is a crime to procure a false registration or to furnish false information to the Board of Elections.
Box 9: You must make one selection. For questions refer to Verifying your identity above.
Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?).
If you voted before under a different name, put down that name. If not, write “Same”.
Box 11: Check one box only. Political party enrollment is optional but that, in order to vote in a primary election of a political
party, a voter must enroll in that political party, unless state party rules allow otherwise.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LDSS-4826 DD(Rev. 218) (monroe county)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document