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: 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.
ldss-2921 statewide (rev. 7/16) do not write in the shaded areas of this application page 1 center/ office ind application date unit id worker id case type serv. case number registry number vers district suffix snap
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