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TANF SERVICES CERTIFICATION

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LDSS-4770 (Rev. 2/16) TANF SERVICES Eligible Statuses and Proof 1 TANF YOUTH SERVICES APPLICATION The information requested on this form is necessary to determine whether or not federal Temporary Assistance for Needy Families (TANF) funds may be used to provide SERVICES to you. This application form may be used by an applicant for SERVICES who is under 21 years of age. ________________________________________ ________________________________________ ___________________ SECTION ONE A. Information About the Youth Applicant 1. Applicant s Name: ________________________________________ ___________ Home Address: ________________________________________ ____________ (Street) (Apartment Number) ________________________________________ ________________________ (City) (State) (Zip Code) Social Security Number: _____________________________

LDSS-4770 (Rev. 2/16) TANF Services Eligible Statuses and Proof 3 SECTION FIVE TANF Youth Services Application Review Form CERTIFICATION ITEM Yes No 1. Is the applicant a New York State resident?

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