Transcription of DENIAL REASON CODE WITHDRAWAL - New York State …
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DENIAL REASON CODE WITHDRAWAL - New York State …
LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 1 CENTER/ OFFICE APPLICATION DATE UNIT ID WORKER ID CASE TYPE SERV. IND CASE NUMBER REGISTRY NUMBER VERS DISTRICT SUFFIX SNAP SUFFIX CATEGORY LANG NUMBER REUSE INDICATOR CASE NAME EFFECTIVE DATE DISPOSITION SERVICES TRANSACTION TYPE NEW OPENING REOPEN RECERTIFICATION DENIAL REASON CODE WITHDRAWAL ELIGIBILITY DETERMINED BY (WORKER): DATE ELIGIBILITY APPROVED BY (SUPERVISOR): DATE SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION DATE FORM _____ 0F _____ x DATE RECEIVED BY AGENCY EMPLOYED BY.
ldss-2921 statewide (rev. 07/20) do not write in the shaded areas of this application . center/ office ind application date unit id worker id suffix case type serv. case number registry number vers district suffix snap category lang number
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