NY LDSS-4002 2006-2025 free printable template
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LDSS-4002 Rev. 11/06 ACTION TAKEN ON YOUR REQUEST FOR ASSISTANCE TO MEET AN IMMEDIATE NEED OR A SPECIAL ALLOWANCE NOTICE DATE PA Only NAME AND ADDRESS OF AGENCY/CENTER OR DISTRICT OFFICE CASE NUMBER CIN NUMBER CASE NAME And C/O Name if Present AND ADDRESS GENERAL TELEPHONE NO.
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How to fill out NY LDSS-4002
01
Obtain the NY LDSS-4002 form from the New York State Office of Temporary and Disability Assistance website or local social services office.
02
Fill in your personal information at the top of the form, including your name, address, and contact information.
03
Provide details about your household, including the names and relationships of all individuals living with you.
04
Indicate your income sources by providing information on wages, benefits, and any other income received.
05
Fill out the expenses section, listing your monthly rent/mortgage, utility bills, and any other necessary living expenses.
06
Review the form for accuracy and completeness before submitting it.
07
Submit the completed form to your local Department of Social Services office either in person or via mail.
Who needs NY LDSS-4002?
01
Individuals or families applying for public assistance programs in New York, such as Temporary Assistance, Supplemental Nutrition Assistance Program (SNAP), or Medicaid.
02
Those seeking to report changes in their financial situation or household composition.
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What is NY LDSS-4002?
NY LDSS-4002 is a form used in New York State to report changes in circumstances that may affect eligibility for public assistance programs.
Who is required to file NY LDSS-4002?
Individuals who are receiving public assistance benefits and experience changes in their circumstances, such as income, household composition, or address, are required to file NY LDSS-4002.
How to fill out NY LDSS-4002?
To fill out NY LDSS-4002, provide accurate information about your current circumstances, including personal details, changes in income or living situation, and any other relevant information as requested on the form.
What is the purpose of NY LDSS-4002?
The purpose of NY LDSS-4002 is to ensure that the public assistance benefits accurately reflect the recipient's current situation, allowing for appropriate adjustments to be made to their benefits.
What information must be reported on NY LDSS-4002?
Information that must be reported on NY LDSS-4002 includes income changes, addition or removal of household members, changes in living arrangements, any assets acquired, and changes in expenses or liabilities.
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