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/ APPLICATION DATE UNIT ID WORKER ID CASE SERV. CASE NUMBER REGISTRY NUMBER VERS DISTRICT SUFFIX SNAP CATEGORY LANG NUMBER. OFFICE TYPE IND SUFFIX REUSE. INDICATOR. CASE NAME DISPOSITION SERVICES TRANSACTION TYPE. EFFECTIVE DATE NEW. OPENING REOPEN RECERTIFICATION. DENIAL REASON CODE WITHDRAWAL 02 10 06. ELIGIBILITY DETERMINED BY (WORKER): DATE ELIGIBILITY APPROVED BY (SUPERVISOR): DATE SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY DATE.
page ldss. 06. 0f x -2921 statewide (rev. 7/16) . do not write in the shaded areas of this application 1 . center/ office . application date . unit id . worker id . case type . serv.
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