The County Executive's Home Page
John F. O'Neill
3085 Veterans Memorial Hwy
Ronkonkoma, NY 11779
Phone: (631) 854-9930
Emergency Services (After 4:30 PM & Weekends, Holidays): (631) 854-9100
(Required to view PDFs)
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
Directory for Public Access to Social Services Programs. Telephone directory and available services.
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.
If you believe an individual has received welfare assistance improperly, please take the time to share this information with us.
Client Benefit Services
LDSS 4530 sp assignment of wages with local address.pdf
Assignment of Wages Local Address - Spanish
LDSS4530 assignment of wages with LOCAL ADDRESS.pdf
Assignment of Wages Local Address
SCO 221 Housing Verification Rev. 5-08.pdf
SCO 221- S HOUSING VERIFICATION SPANISH.pdf
Housing Verification - Spanish
SCO 2232-C Consent for Verification of Info.pdf
Consent for Verification of Info
SCO 227 S Verification of school attendance-Spanish.pdf
Verification of school attendance - Spanish
SCO 227 Verification of school attendance.pdf
Verification of school attendance
SCO 2395 SSP App.pdf
SCO 2565 Shelter Arrears Breakdown 8 13.pdf
Shelter Arrears Breakdown
SCO 2565S Shelter Arrears Breakdown Spanish 8.13.pdf
Shelter Arrears Breakdown - Spanish
DOH-4287 NOA Continuing your MED-FHP (6-08).pdf
Continuing your Medicaid or Family Health Plus Benefits
DOH-4443 Financial Maintenance.pdf
Financial Maintenance form for listing monthly expenses
Self-Declaration of Income
New York State Forms
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.
Companion Instructions to the DSS 2921
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.
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.
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.
Custodial parents not in receipt of TANF must complete this application. The application authorizes the Child Support Bureau to begin action on their behalf.
What you should know about Child Support Services and Application/Referral for Child Support Services.
This application can only be used to apply for Supplemental Nutrition Assistance Program (SNAP) Benefits.
Copyright 2014, Suffolk County Government
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