LDSS-5084 DD (Rev. 11/17)


If you are blind or seriously visually impaired and need this form or the three informational books in an alternative format (large print, audio, data CD, or Braille) contact your social services district. Large print, audio and data files are also available for download at under “Forms”. If you require another accommodation, please contact your local social services district office.

This form and the three informational books are offered in multiple languages and are available online at under “Forms”. To view the books follow the link provided, click “Forms” and scroll down until you see the titles of the books. The book titles are listed below.

You may also pick up printed books at your local District Offices or have them mailed to you at any time upon request.

Book1: What You Should Know About Your Rights and Responsibilities (LDSS-4148A)

This book informs you about your rights and responsibilities when applying for and receiving benefits.

Book 2: What You Should Know About Social Services Programs (LDSS-4148B)

This book gives information about the different programs available - such as Temporary Assistance (TA), Supplemental Nutrition Assistance Program (SNAP) as well as Medical Assistance (MA) (which includes Medicaid, Family Health Plus, and Family Planning Benefit Program). It also provides information on other services including child care, foster care, child welfare, adoption and other available programs.

Book 3: What You Should Know If You Have an Emergency (LDSS-4148C)

This book tells you what to do in case you have an emergency - such as needing immediate help with shelter, food, utility, fuel expenses, or medical attention.

You are entitled to information about your rights and responsibilities as an applicant or recipient of services and benefit programs.

The valuable information in these books can help you in applying for and receiving benefits. It is very important that you read these books and understand the information. If you have any questions after reading the books, or need help accessing the information, you may contact your district office for assistance.

Hearing impaired callers can use the New York State Relay service by dialing 711 or TTY phone numbers of 1-800-421-1220 or 1-800-662-1220