Transcription of NEW YORK STATE APPLICATION FOR CERTAIN …
{{id}} {{{paragraph}}}
Example: barber
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. INFORMATION. FORM _____. 0F _____ x DATE RECEIVED BY AGENCY. EMPLOYED BY: SOCIAL SERVICES DISTRICT PROVIDER AGENCY SPECIFY: PA AUTHORIZATION PERIOD MA AUTHORIZATION PERIOD SNAP AUTHORIZATION PERIOD SERVICES AUTHORIZATION PERIOD. FROM TO FROM TO FROM TO FROM TO. NEW YORK STATE APPLICATION FOR CERTAIN BENEFITS AND SERVICES. If you are blind or seriously visually impaired and need this APPLICATION in an alternative format, you may request one from your social services district.
statewide spanish what is your page 2 do not write in the shaded areas of this application ldss-2921 (rev. 7/16)
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document:
Related search queries
STAINLESS STEEL LEAN DUPLEX SECTIONS, LDSS, This application can ONLY be used, New york state office of temporary and disability assistance, Suspected Child Abuse or Maltreatment, Electronic Benefit Transfer, Electronic Benefit Transfer EBT, Suffolk County Child Support, Suffolk County Child Support Services: Call, Summary Guide for Mandated Reporters, NycACS REV. 2/06 DIVISION OF, DIVISION OF CHILD CARE AND, Mandated Reporter SCR Call Tip Sheet