Contact Us

Contact Us Online

John F. O'Neill
Commissioner
Address:
3085 Veterans Memorial Hwy
Ronkonkoma, NY 11779

Click here to find the Center serving you:  

Service Center Hours: Monday through Friday 8:00AM-3:00PM, excluding county holiday closures. Language Services available at all sitesAccess to Services in Your Language: Complaint Form

Phone: (631) 854-9930

Emergencies (After 4:30 PM & Weekends): (631) 854-9100 

If you asked for an accommodation and did not receive it contact:
ADA Compliance Officer or People with Disabilities

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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

Child Support Enforcement

4130CSEBIntakeQuestionnaireChildSupport403.pdf

This questionnaire will provide the basic information needed to enable CSEB to build a case in the Child Support Management System and to take the first steps to assist the custodial parent in obtaining child support.

6

Client Benefit Services

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
Client Benefit Services
LDSS-4826: SNAP Benefits Application

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

9