NY LDSS-5023 2015-2025 free printable template

LDSS-5023 Rev. 2/15 NYS Office of Temporary Disability Assistance Congregate Care Change Report Form I. Return Instructions Please return this completed form to By E-mail By Fax Mailing Address otda*sm*ssp otda*ny. gov 518 486-3459 SSI State Supplement Program PO Box 1740 Albany New York 12201 II. Client Identification Name Social Security Number last four XXX-XXX- Date of Birth / New Residence Address New Provider Name and Address Former Provider Name and Address County...

How to fill out congregate care change form ny ldss 5023

How to fill out NY LDSS-5023

1. Obtain the NY LDSS-5023 form from the New York State Office of Temporary and Disability Assistance website or your local social services office.
2. Fill in the applicant's name, address, and contact information at the top of the form.
3. Indicate the type of assistance being requested in the appropriate section.
4. Provide details about household members, including their names, dates of birth, and relationship to the applicant.
5. Complete the income section by listing all sources of income for the household, including wages, benefits, and any other financial support.
6. Complete the expenses section, detailing monthly housing costs, utilities, and any other relevant financial obligations.
7. Sign and date the form at the bottom, certifying that the information provided is accurate to the best of your knowledge.
8. Submit the completed form to your local social services office either in person or by mail.

Who needs NY LDSS-5023?

1. Individuals or families in New York State who are applying for or receiving public assistance benefits, such as Temporary Assistance, Medicaid, or food assistance.

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What is ldss 5023?

LDSS 5023 refers to a form used by the New York State Office of Temporary and Disability Assistance for the application process of various human service programs. It is specifically used for the application of Temporary Assistance, commonly known as welfare benefits. The form collects information about the applicant's household, income, expenses, and other relevant details required to determine their eligibility for the program.

Who is required to file ldss 5023?

The LDSS 5023 form is typically required to be filed by individuals or households applying for public assistance programs, such as Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), Medicaid, and Home Energy Assistance Program (HEAP). The specific eligibility criteria and requirements may vary depending on the state or region. It is important to consult with the relevant social services agency or department for accurate information and instructions.

How to fill out ldss 5023?

To correctly fill out LDSS-5023, please follow the steps below: 1. Head to the New York State Office of Temporary and Disability Assistance website and locate the LDSS-5023 form. It is also available at local social service offices. 2. Begin by providing your personal information, such as your name, address, and contact details in the appropriate sections of the form. 3. If you are applying on behalf of someone else, fill in their information in the relevant sections. 4. Specify the assistance programs you wish to apply for by marking the corresponding boxes on the form. These may include programs like Temporary Assistance (TA), Medicaid, or Supplemental Nutrition Assistance Program (SNAP). 5. Next, indicate the number of people living in your household, including yourself, your spouse, children, and anyone else you support financially. 6. Proceed to complete the "Household Expenses" section by listing all the monthly expenses you incur, including rent/mortgage, utilities, child care, and medical costs. Be sure to include accurate figures. 7. Detail the sources of your income, such as wages, self-employment, unemployment benefits, Social Security, pensions, or any other form of income that applies to your situation. 8. If you have any deductions or expenses that can be subtracted from your income, clearly state them. These might include childcare expenses, child support payments, medical expenses, or court-ordered payments. 9. Provide information about any assets you may have, such as bank accounts, property, real estate, or vehicles. Include their current value as accurately as possible. 10. Finally, sign and date the form and ensure you have completed all necessary sections. Keep a copy of the completed form for your records, and submit the original to the appropriate social service office either in person or by mail. Note: It's crucial to answer all questions truthfully and provide accurate and complete information. Providing false information on government forms is illegal and may result in penalties or consequences. If you have any uncertainties or need additional assistance, consider consulting with a social worker or a representative at the local social service office.

What is the purpose of ldss 5023?

The primary purpose of LDSS 5023 is to provide a document that serves as a verification of performance hours for individuals who are required to meet specific work or volunteer requirements in order to receive certain benefits or services, such as certain types of public assistance or child support programs. The LDSS 5023 form is typically completed by a supervisor or authorized representative who can confirm the individual's performance or participation in the required activities. This document is often used as proof for eligibility or compliance with program requirements.

What information must be reported on ldss 5023?

The LDSS 5023 form is a report that must be completed by mandated reporters, such as doctors, teachers, social workers, etc., when they suspect or have knowledge of child abuse or maltreatment. The information that needs to be reported on LDSS 5023 includes: 1. Personal Information: The name, contact information, and relationship to the child of the person making the report. 2. Child Information: The name, age, gender, address, and contact information of the child being reported. 3. Alleged Abuse or Neglect Details: A detailed description of the suspected abuse or neglect, including dates, times, locations, nature, and the severity of the incidents. 4. Perpetrator Information: If known, the name, relationship to the child, address, and contact information of the alleged perpetrator. 5. Child and Family Background: Relevant information about the child and their family, such as any known medical history, prior reports of abuse or neglect, parenting concerns, substance abuse issues, mental health concerns, etc. 6. Witnesses or Collateral Contacts: Names, contact information, and statements provided by any witnesses or individuals who may have additional information about the suspected abuse or neglect. 7. Any Actions or Interventions: Information on any actions already taken by the reporter or others involved, such as contacting law enforcement, removing the child from their home, providing emergency medical care, etc. 8. Reporter's Signature and Date: The reporter must sign and date the report to verify its accuracy and completion. It's essential to note that specific reporting requirements may vary depending on the jurisdiction or state where the report is being filed.

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What is NY LDSS-5023?

NY LDSS-5023 is a form used in New York State for reporting changes in circumstances for public assistance and food stamp recipients.

Who is required to file NY LDSS-5023?

Individuals who receive public assistance, food stamps, or other benefits from New York State are required to file NY LDSS-5023 when there are changes in their household situation.

How to fill out NY LDSS-5023?

To fill out NY LDSS-5023, provide accurate information regarding your household members, income, expenses, and any changes in your circumstances. Be sure to follow the instructions provided with the form.

What is the purpose of NY LDSS-5023?

The purpose of NY LDSS-5023 is to ensure that the correct amount of public assistance or food stamp benefits is provided based on any updates in a recipient's financial or household status.

What information must be reported on NY LDSS-5023?

Information that must be reported on NY LDSS-5023 includes changes to income, household composition, living arrangements, medical expenses, and any other relevant circumstances affecting eligibility for benefits.