HRA - Applications

Human Resources Administration / Department of Social Services

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	Common Application for Temporary Assistance, Medical Assistance, Food Stamp Benefits, and Services including Foster Care and Child Care Assistance Application (LDSS 2921) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) How to Complete Application (LDSS 1301) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) Recertification Form for Temporary Assistance, Medical Assistance, Medicare Savings Program, and Food Stamp Benefits Recertification Form (LDSS 3174) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) How to Complete the Recertification Form (LDSS 1313) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) Food Stamps Benefits Application, Instructions for Completion, Request for Replacement of Food Purchased with Food Stamps Food Stamps Application (LDSS 4826) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) How to Complete the Food Stamps Benefit Application (LDSS 4826A) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) Child Care Provider Forms Child Care Provider Enrollment Supplement (CS-274W) English Español (Spanish) 中文(Chinese) (Arabic) عربي 한국어(Korean) Kreyòl Ayisyen (Haitian Creole) Русский (Russian) (OCFS-LDSS-4699) Provider of Legally-Exempt Family Child Care and Legally-Exempt In-Home Child Care Enrolment Form (OCFS-LDSS-4699-1) Employment of Minors Form (OCFS-LDSS-4699-1S) Employment of Minors Form Español (Spanish) (OCFS-LDSS-4699-1A) Employment of Minors Information (OCFS-LDSS-4699-2) Legally-Exempt In-Home Child Care Provider Agreement Form (OCFS-LDSS-4699-2A) Parental Responsibilities When Employing a Legally-Exempt In-Home Child Care Provider (OCFS-LDSS-4699-2S) Español (Spanish) (OCFS-LDSS-4699-3) Legally Exempt Child Care Provider Training Record Form (OCFS-LDSS-4699-3S) Español (Spanish) (OCFS-LDSS-4699-4) Parental Acknowledgment (OCFS-LDSS-4699-4S) Español (Spanish) (OCFS-LDSS-4700) Provider of Legally-Exempt Group Child Care Enrollment Form (OCFS-LDSS-4700S) Español (Spanish) Child Support : English What You Should Know About Your Rights and Responsibilities (LDSS 4148A) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) 한국어 (Korean) Français (french) Tiếng Việt (Vietnamese) Yiddish What You Should Know About Social Services Program (LDSS 4148B) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) 한국어 (Korean) Français (french) Tiếng Việt (Vietnamese) Yiddish What You Should Know If You Have An Emergency (LDSS 4148C) : English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) 한국어 (Korean) Français (french) Tiếng Việt (Vietnamese) Yiddish Health Care DOH-4220, Health Insurance Application/ACCESS NY Health Care for Children Adults application and Access NY Supplement A Instructions: English Español (Spanish) DOH 4220 Application: English Español (Spanish) Documents Needed When You Apply: English Español (Spanish) Fact Sheet: English Español (Spanish) For More Information and Assistance please visit: http://www.health.ny.gov/health_care/family_health_plus/application.htm Medicare Savings Program only application (DOH 4328): English Español (Spanish) Family Planning Benefit Program (DOH 4282) If you do not speak English well: English Español (Spanish) Русский (Russian) (Arabic) عربي 中文 (Chinese) Kreyòl Ayisyen (Haitian Creole) 한국어 (Korean) I Speak Card (PDF) Absent Parent Questionnaire (Recertification) (PDF) This form asks questions about the non-custodial parent of each child on the cash assistance case. The information obtained from this form will be used to establish/update a claim for child support. This form is used at the cash assistance recertification interview. Absent Parent Questionnaire (Application) (PDF) This form asks questions about the non-custodial parent of each child applying for cash assistance. The information obtained from this form will be used to establish/update a claim for child support. This form is used at the cash assistance application interview. Application for Life Line Telephone Service (PDF) This form is used to apply for a reduced telephone rate provided by Verizon via their Life Line program. The form provides information on documentation needed to verify eligibility. Burial Claims Process & Applications (PDF) The Human Resources Administration (HRA) will provide financial assistance to individuals in need of assistance to meet funeral expenses. These funds are available when an indigent resident of New York City dies who may have been in receipt of SSI, CA, or no public benefits at all, without leaving funds to cover their burial expenses and there are no relatives or friends willing or able to pay the funeral expenses. Applications for Burial Allowance (PDFs) English Español (Spanish) Русский (Russian) (Arabic) عربي 中文(Chinese) Kreyòl Ayisyen (Haitian Creole) 한국어(Korean) Request for Additional Allowance (PDF) This form is used to request an additional allowance, report a change in your household that may affect your budget, or to add a person to the case. Note: This form is also used to request a change or correction of address, even if there no request for an additional allowance. Request for Payment of Rent Arrears in Excess of Agency (PDF)* This form is used to request the payment of rent arrears (back rent) when your monthly rent is greater than the allowance you receive from HRA. This form is also used as an agreement for another person who is willing and able to help you pay the excess rent in the future. Request for Review for Underpayment (PDF) This form is to request a review of your case record to determine if your cash assistance grant is correct. Primary Tenant's Statement Regarding Occupancy of Secondary Tenant (PDF) This form is used in shared housing situations for the primary tenant to confirm that an individual is residing in his/her apartment as a secondary tenant. This form also documents the rent charged by the primary tenant to the secondary tenant.