Transcription of NEW YORK STATE APPLICATION FOR CERTAIN …
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NEW YORK STATE APPLICATION FOR CERTAIN …
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.
When you see MA“ ” on the application, it means Medicaid“ .” You may apply for MA using this application only if you are also applying for Public Assistance the or Supplemental Nutrition Assistance Programat the same time.
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