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NY LDSS-3559 2013-2025 free printable template

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This form is used to report the admission, discharge, readmission, or change in status of a Medicaid recipient in a residential health care facility to the local department of social services.
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How to fill out NY LDSS-3559

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How to fill out NY LDSS-3559

01
Begin by downloading the NY LDSS-3559 form from the official New York State website.
02
Fill in your personal information at the top of the form, including your name, address, and contact information.
03
Indicate your program type (e.g., SNAP, Medicaid) in the designated section.
04
Provide details about your household members, including their names, dates of birth, and relationships to you.
05
Include information about your income and employment for each household member as required.
06
List any expenses you incur, such as rent or childcare, in the appropriate sections.
07
Review the form for completeness and accuracy before signing and dating it at the bottom.
08
Submit the form to your local Department of Social Services office by mail or in person.

Who needs NY LDSS-3559?

01
Individuals or families applying for or recertifying for assistance programs such as SNAP (Supplemental Nutrition Assistance Program) or Medicaid in New York State.
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NY LDSS-3559 is a form used by the New York State Department of Social Services to report changes in income or household composition for individuals receiving public assistance.
Individuals receiving public assistance who experience changes in their income or household situation are required to file NY LDSS-3559.
To fill out NY LDSS-3559, you should provide accurate information about your current income, household members, and any changes that have occurred since your last report.
The purpose of NY LDSS-3559 is to ensure that the Department of Social Services has up-to-date information to assess eligibility and determine the correct levels of assistance.
Information that must be reported includes details about income sources, changes in employment, household size, and any other factors that may affect eligibility for public assistance.
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