Social Services

How Do I...?

Search Program Area

Contact Us

John F. O'Neill
Commissioner
Address:
3085 Veterans Memorial Hwy
Ronkonkoma, NY 11779
Phone: (631) 854-9930

Emergency Services (After 4:30 PM & Weekends, Holidays): (631) 854-9100 

Click here to leave feedback

Get Adobe Reader
(Required to view PDFs)

Public Forms

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

Directory for Public Access to Social Services Programs

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

14

Directory For Public Access to Social Services Programs (Spanish version) 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 Care Services

CCB-6010-001 Application for Child Care Subsidy

CCB-6010-001 Spanish Version

To apply for subsidized child care, this application must be completed, signed and dated.  See below for additional forms that must be completed and required documentation that must be submitted together with the application.

 3

CCB-6010-001 (Inst) Instructions for Completing Your Application for Child Care Subsidy

CCB-6010-001(Inst.) Spanish Version

Step by step instructions for applying for subsidized child care

 2

Documentation Required for Child Care Eligibility

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.

 1

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-6010-008 Release of Client Information Form

CCB-6010-008 Spanish Version

Complete this form to give permission for DSS to share information regarding your case with specific persons (for example, your child care provider(s), an Advocate who is helping you apply for a child care subsidy, etc.)  A separate form has to be completed for each person with whom you are allowing DSS to share your information.

 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

 Client Benefit Services

Housing Package Housing Package Forms for Tenant, Broker, Landlord

 15

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 April 2015) 

 32

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

SCO IM 206 Confidential Employment Inquiry.pdf Confidential Employment Inquiry

2

SCO IM 206- S Confidential Employment Inquiry Spanish.pdf Confidential Employment Inquiry - Spanish

2

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-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