Forms

Forms

If you are blind or visually impaired many of OTDA’s forms are available in alternative format.

Application for Certain Benefits and Services

Common application for Public Assistance, Child Care in Lieu of Public Assistance, the Supplemental Nutrition Assistance Program (SNAP), Medicaid and SNAP, Medicaid and Public Assistance, Services included Foster Care, Child Care Assistance, and Emergency Assistance only.

• Application for Certain Benefits and Services (LDSS-2921)
  • LDSS-2921 - Arabic, LDSS-2921 - Chinese, LDSS-2921 - Haitian-Creole, LDSS-2921 - Italian, LDSS-2921 - Korean, LDSS-2921 - Russian, LDSS-2921 - Spanish
• Instructions for Completing the Application for Certain Benefits and Services (PUB-1301)
  • LDSS-1301 - Arabic, LDSS-1301 - Chinese, LDSS-1301 - Haitian-Creole, LDSS-1301 - Italian, LDSS-1301 - Korean, LDSS-1301 - Russian, LDSS-1301 - Spanish

Recertification Form for Certain Benefits and Services

Recertification form for Public Assistance, Supplemental Nutrition Assistance Program (SNAP), Medicaid and SNAP, and Medicaid and Public Assistance.

• Recertification Form for Certain Benefits and Services (LDSS-3174)
  • LDSS-3174 - Arabic, LDSS-3174 - Chinese, LDSS-3174 - Haitian-Creole, LDSS-3174 - Italian, LDSS-3174 - Korean, LDSS-3174 - Russian, LDSS-3174 - Spanish
• Instructions for Completing the Recertification for Certain Benefits and Services Form (PUB-1313)
  • LDSS-1313 - Arabic, LDSS-1313 - Chinese, LDSS-1313 - Haitian-Creole, LDSS-1313 - Italian, LDSS-1313 - Korean, LDSS-1313 - Russian, LDSS-1313 - Spanish

Supplemental Nutrition Assistance Program (SNAP) Benefits

• SNAP Application/Recertification (LDSS-4826)
  • LDSS-4826 - Arabic, LDSS-4826 - Chinese, LDSS-4826 - Haitian-Creole, LDSS-4826 - Italian, LDSS-4826 - Korean, LDSS-4826 - Russian, LDSS-4826 - Spanish
• Instructions for Completing the SNAP Application/Recertification (LDSS-4826A)
  • LDSS-4826A - Arabic, LDSS-4826A - Chinese, LDSS-4826A - Haitian-Creole, LDSS-4826A - Italian, LDSS-4826A - Korean, LDSS-4826A - Russian, LDSS-4826A - Spanish
• Request for Replacement of Food Purchased with Supplemental Nutrition Assistance Program (SNAP) Benefits (English/Spanish) (LDSS-2291)
  • LDSS-2291 - English/Arabic, LDSS-2291 - English/Chinese, LDSS-2291 - English/Haitian-Creole, LDSS-2291 - English/Italian, LDSS-2291 - English/Korean, LDSS-2291 - English/Russian, LDSS-2291 - English/Spanish
• Supplemental Nutrition Assistance Program (SNAP) Authorized Representative Request Form (LDSS-4942)
  • LDSS-4942 - Arabic, LDSS-4942 - Chinese, LDSS-4942 - Haitian-Creole, LDSS-4942 - Italian, LDSS-4942 - Korean, LDSS-4942 - Russian, LDSS-4942 - Spanish
• Supplemental Nutrition Assistance Program (SNAP) Change Report Form (LDSS-3151)
  • LDSS-3151 - Arabic, LDSS-3151 - Chinese, LDSS-3151 - Haitian-Creole, LDSS-3151 - Italian, LDSS-3151 - Korean, LDSS-3151 - Russian, LDSS-3151 - Spanish

SCAM Alert

Scammers offer phony SNAP application assistance

Home Energy Assistance Program (HEAP)

The HEAP application is available when HEAP is open.

• Home Energy Assistance Program (HEAP) Application (LDSS-3421)
  • LDSS-3421 - Arabic, LDSS-3421 - Chinese, LDSS-3421 - Haitian-Creole, LDSS-3421 - Italian, LDSS-3421 - Korean, LDSS-3421 - Russian, LDSS-3421 - Spanish
• Qualified Alien Definition (LDSS-4998)
  • LDSS-4998 Arabic, LDSS-4998 Chinese, LDSS-4998 Haitian-Creole, LDSS-4998 Italian, LDSS-4998 Korean, LDSS-4998 Russian, LDSS-4998 Spanish

State Supplement Program (SSP)

• Living Arrangement Form (LDSS-5030)
  • LDSS-5030 Arabic, LDSS-5030 Chinese, LDSS-5030 Haitian-Creole, LDSS-5030 Italian, LDSS-5030 Korean, LDSS-5030 Russian, LDSS-5030 Spanish
• Direct Deposit Enrollment Form for SSP Recipients (LDSS-5025)
  • LDSS-5025 Arabic, LDSS-5025 Chinese, LDSS-5025 Haitian-Creole, LDSS-5025 Italian, LDSS-5025 Korean, LDSS-5025 Russian, LDSS-5025 Spanish
• Direct Deposit Cancellation Form for SSP Recipients (LDSS-5067)
  • LDSS-5067 Arabic, LDSS-5067 Chinese, LDSS-5067 Haitian-Creole, LDSS-5067 Italian, LDSS-5067 Korean, LDSS-5067 Russian, LDSS-5067 Spanish
• Income Verification Form (LDSS-5040)
  • LDSS-5040 Arabic, LDSS-5040 Chinese, LDSS-5040 Haitian-Creole, LDSS-5040 Italian, LDSS-5040 Korean, LDSS-5040 Russian, LDSS-5040 Spanish
• Marital Status Change Form (LDSS-5035)
  • LDSS-5035 Arabic, LDSS-5035 Chinese, LDSS-5035 Haitian-Creole, LDSS-5035 Italian, LDSS-5035 Korean, LDSS-5035 Russian, LDSS-5035 Spanish
• Designated Representative Form (LDSS-5024)
  • LDSS-5024 Arabic, LDSS-5024 Chinese, LDSS-5024 Haitian-Creole, LDSS-5024 Italian, LDSS-5024 Korean, LDSS-5024 Russian, LDSS-5024 Spanish
  • Rights and Responsibilities of Designated Representatives for the State Supplement Program (LDSS-5032)
    • LDSS-5032 Arabic, LDSS-5032 Chinese, LDSS-5032 Haitian-Creole, LDSS-5032 Italian, LDSS-5032 Korean, LDSS-5032 Russian, LDSS-5032 Spanish
• Congregate Care Change Report Form (LDSS-5023)
  • LDSS-5023 Arabic, LDSS-5023 Chinese, LDSS-5023 Haitian-Creole, LDSS-5023 Italian, LDSS-5023 Korean, LDSS-5023 Russian, LDSS-5023 Spanish

Child Support Services

• Application for Child Support Services (LDSS-4882)
  • LDSS-4882 - Arabic, LDSS-4882 - Chinese, LDSS-4882 - Haitian-Creole, LDSS-4882 - Italian, LDSS-4882 - Korean, LDSS-4882 - Russian, LDSS-4882 - Spanish
• Information about Child Support Services (LDSS-4882A)
  • LDSS-4882A - Arabic, LDSS-4882A - Chinese, LDSS-4882A - Haitian-Creole, LDSS-4882A - Italian, LDSS-4882A - Korean, LDSS-4882A - Russian, LDSS-4882A - Spanish
• Information for an Additional Noncustodial Parent (NCP)/Putative Father (PF) (LDSS-4882B)
  • LDSS-4882B - Arabic, LDSS-4882B - Chinese, LDSS-4882B - Haitian-Creole, LDSS-4882B - Italian, LDSS-4882B - Korean, LDSS-4882B - Russian, LDSS-4882B - Spanish
• Information for an Additional Child (LDSS-4882C)
  • LDSS-4882C - Arabic, LDSS-4882C - Chinese, LDSS-4882C - Haitian-Creole, LDSS-4882C - Italian, LDSS-4882C - Korean, LDSS-4882C - Russian, LDSS-4882C - Spanish

Temporary Assistance for Needy Families (TANF)

• TANF Services Certification (LDSS-4726)
  • LDSS-4726 Arabic, LDSS-4726 Chinese, LDSS-4726 Haitian-Creole, LDSS-4726 Italian, LDSS-4726 Korean, LDSS-4726 Russian, LDSS-4726 Spanish
• Youth Application for TANF Services (LDSS-4770)
  • LDSS-4770 Arabic, LDSS-4770 Chinese, LDSS-4770 Haitian-Creole, LDSS-4770 Italian, LDSS-4770 Korean, LDSS-4770 Russian, LDSS-4770 Spanish

Application Booklets

Information on your rights and responsibilities, and the services and programs available to you.

• What You Should Know About Your Rights and Responsibilities (LDSS-4148A)
  • LDSS-4148A Arabic, LDSS-4148A Chinese, LDSS-4148A Haitian-Creole, LDSS-4148A Italian, LDSS-4148A Korean, LDSS-4148A Russian, LDSS-4148A Spanish
• What You Should Know About Social Services Programs (LDSS-4148B)
  • LDSS-4148B Arabic, LDSS-4148B Chinese, LDSS-4148B Haitian-Creole, LDSS-4148B Italian, LDSS-4148B Korean, LDSS-4148B Russian, LDSS-4148B Spanish
• Important Changes in the Medicaid Program (Supplement to LDSS-4148A and LDSS-4148B)
  • LDSS-4148A and LDSS-4148B Supplement - Arabic, LDSS-4148A and LDSS-4148B Supplement - Chinese, LDSS-4148A and LDSS-4148B Supplement - Haitian-Creole, LDSS-4148A and LDSS-4148B Supplement - Italian, LDSS-4148A and LDSS-4148B Supplement - Korean, LDSS-4148A and LDSS-4148B Supplement - Russian, LDSS-4148A and LDSS-4148B Supplement - Spanish
• What You Should Know If You Have an Emergency (LDSS-4148C)
  • LDSS-4148C Arabic, LDSS-4148C Chinese, LDSS-4148C Haitian-Creole, LDSS-4148C Italian, LDSS-4148C Korean, LDSS-4148C Russian, LDSS-4148C Spanish
• Accessing Applicant/Recipient Informational Books (LDSS-5084)
  • LDSS-5084 Arabic, LDSS-5084 Chinese, LDSS-5084 Haitian-Creole, LDSS-5084 Italian, LDSS-5084 Korean, LDSS-5084 Russian, LDSS-5084 Spanish

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