Public Forms

To view all the local Department of Social Services forms, please click on link.

For a complete listing of Common Forms and Applications from the NYS Office of Temporary and Disability Assistance as well as the following state forms and applications in languages other than English, please click here.

Please print or download form to your computer.
Follow the instructions on each form and print or type legibly.

Social Services Forms

 

Social Services Forms

Form

Description

Pages

DFPAFeb2014.pdf

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

14

DFPASpanishFeb2014.pdf Directory for Public Access to Social Services Programs (Spanish version). Telephone directory and available services.

15

ThreatsManual2014.pdf

It is the intent of the Suffolk County Department of Social Services to create a safe workplace for staff and the public who access our services.

28

WebFraudReportingForm.pdf

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

1

Client Benefit Services

Housing Package Housing Package Forms for Tenant, Broker, Landlord

 15

LDSS 4530 sp assignment of wages with local address.pdf

Assignment of Wages Local Address - Spanish 

2

LDSS4530 assignment of wages with LOCAL ADDRESS.pdf

Assignment of Wages  Local Address

3

SCO 221 Housing Verification Rev. 5-08.pdf

Housing Verification

2

SCO 221- S HOUSING VERIFICATION SPANISH.pdf

Housing Verification - Spanish

2

SCO 2232-C Consent for Verification of Info.pdf

Consent for Verification of Info

1

SCO 227 S Verification of school attendance-Spanish.pdf

Verification of school attendance - Spanish

1

SCO 227 Verification of school attendance.pdf

Verification of school attendance

1

SCO 2395 SSP App.pdf

SSP Application

3

SCO 2565 Shelter Arrears Breakdown 8 13.pdf

Shelter Arrears Breakdown

1

SCO 2565S Shelter Arrears Breakdown Spanish 8.13.pdf

Shelter Arrears Breakdown - Spanish

1

Medicaid Services

DOH-4287 NOA Continuing your MED-FHP (6-08).pdf

Continuing your Medicaid or Family Health Plus Benefits

11

DOH-4443 Financial Maintenance.pdf

Financial Maintenance form for listing monthly expenses

1

DOH-5017_VerificationOfEmployment_OHIP.pdf Verification of Employment

1

DOH-5018_SelfDeclarationOfIncome_OHIP.pdf

Self-Declaration of Income

1

 

New York State Forms

New York State Forms

Form Description Pages
LDSS-2921: Application for Public Assistance - Medical Assistance - SNAP - Services

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

Companion Instructions to the DSS 2921

10

 LDSS-4148A What You Should Know About Your Rights and Responsibilities (when applying for or receiving benefits)

 35

 LDSS-4148B What You Should Know About Social Services Programs - Q & A

 44

 LDSS-4148C  What You Should Know If You Have An Emergency

 7

Medicaid/DOH

DOH-4220 Access New York Health Care Application

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. If the applicant is disabled, age 65 or older, or in receipt of Nursing Home care, they must complete DOH-4495a (Supplement A).  In addition to the Medicaid application DOH-4220 above, 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

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

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

Child Support Enforcement Bureau
LDSS-2521: Application for Child Support

Custodial parents not in receipt of TANF must complete this application. The application authorizes the Child Support Bureau to begin action on their behalf.

1

LDSS-4882W: Information about Child Support Services

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

16 
Client Benefit Services
LDSS-4826: SNAP Benefits Application

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

9