Supplemental Nutrition Assistance Program (Snap) Application/recertification (Page 2 of 7) in pdf

LDSS-4826

Page 1

(Rev.8/12)

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

SNAP APPLICATION / RECERTIFICATION

Application Date

Interview Date

Center/Office

Unit

Worker

Case Type Case Number

Registry Number

Version

Lifeline

Lang

Apply

Recertify

Name: _________________________ Telephone Number: _________________Other phone where you can be reached: _____________

Residence Address: _____________________________ Apt.# ____ City ___________________, NY Zip Code ________________

Mailing Address (if different) _______________________ Apt.# ____ City ___________________, NY Zip Code ________________

Other Name: __________________ Are You:

Applying or

Recertifying

Do you want to receive notices in:

Spanish and English or

English Only

APPLICANT/REPRESENTATIVE SIGNATURE

DATE SIGNED

We must accept your application if, at a minimum, it contains your name,

address (if you have one), and signature in this box.

List everyone who lives with you even if they are not applying. List yourself first.

Do you buy

Sex

and/

Is this

Hispanic

Enter Y (Yes) or N (No) for

or prepare food

Social Security Number

person

Relationship

each race*

Marital

with this

(SSN) of applying member

applying?

First Name

Last Name

Date of Birth

Latino?

to you

(If none, write “NONE”)

Status

person?

Yes



self 

Race/Ethnic Codes:

)

I – Native American or Alaskan Native, A - Asian, B – Black or African American, P – Native Hawaiian or Pacific Islander, W – White, U – Unknown (MA Only

Are you and is everyone living with you a US citizen? □ Yes

No If No, who is not a citizen?

Has a court issued a warrant because it found that you or anyone living with you is fleeing to avoid prosecution, custody or confinement for a felony or an attempted felony?

Yes

Are you or is anyone living with you in violation of probation or parole according to a court?

Yes

Have you or has anyone living with you ever been disqualified from receiving SNAP because of fraud or intentional program violation?

Yes

Are you or is anyone in your household applying for or receiving SNAP or Temporary Assistance in another place?

Yes

Are you or is anyone living with you blind, disabled or pregnant?

Yes

No If Yes, who

Are you or is anyone living with you a veteran?

Yes

No If Yes, who

Do you or does anyone live in a drug or alcohol treatment center, State-certified group living facility or State-certified supervised/supportive apartment?

Yes

If you are recertifying for SNAP, list on the Page 6 what has changed since your last application or recertification (such as moved, had a baby, someone moved in or out of your household).

You may use the page 6 if you need more room or there is other information that you think we might need.

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