Alternative Format Forms

If you are blind or visually impaired — you have choices on how you receive information.

You can choose to download the forms listed below or you can contact your local department of social services to request the forms listed below. Forms are available in the following formats.

• Audio Disc (AD) — an audio transcription of the form,
• Data Disc (DD) — a screen reader accessible form,
• Large Print (LP), and
• Braille (BR). (Not available online — to order please write or call your local department of social services)

To order alternative format applications please write or call your local department of social services.

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 AD
  • LDSS-2921 AD (Spanish)
• LDSS-2921 DD
  • LDSS-2921 DD (Spanish)
• LDSS-2921 LP
  • LDSS-2921 LP (Spanish)
• LDSS-2921 BR (Not available online.)

Instructions for Completing the Application for Certain Benefits and Services (PUB-1301)

• PUB-1301 AD
  • PUB-1301 AD (Spanish)
• PUB-1301 DD
  • PUB-1301 DD (Spanish)
• PUB-1301 LP
  • PUB-1301 LP (Spanish)
• PUB-1301 BR (Not available online.)

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 AD
  • LDSS-3174 AD (Spanish)
• LDSS-3174 DD
  • LDSS-3174 DD (Spanish)
• LDSS-3174 LP
  • LDSS-3174 LP (Spanish)
• LDSS-3174 BR (Not available online.)

Instructions for Completing the Recertification for Certain Benefits and Services Form (PUB-1313)

• PUB-1313 AD
  • PUB-1313 AD (Spanish)
• PUB-1313 DD
  • PUB-1313 DD (Spanish)
• PUB-1313 LP
  • PUB-1313 LP (Spanish)
• PUB-1313 BR (Not available online.)

Supplemental Nutrition Assistance Program (SNAP) Benefits

SNAP Application/Recertification (LDSS-4826)

• LDSS-4826 AD
  • LDSS-4826 AD (Spanish)
• LDSS-4826 DD
  • LDSS-4826 DD (Spanish)
• LDSS-4826 LP
  • LDSS-4826 LP (Spanish)
• LDSS-4826 BR (Not available online.)

Request for Replacement of Food Purchased with Supplemental Nutrition Assistance Program (SNAP) Benefits (English/Spanish) (LDSS-2291)

• LDSS-2291 AD
• LDSS-2291 DD
• LDSS-2291 LP
• LDSS-2291 BR (Not available online.)

How to Complete the SNAP Application/Recertification and Applicant/Recipient Rights and Responsibilities (LDSS-4826A)

• LDSS-4826A AD
  • LDSS-4826A AD (Spanish)
• LDSS-4826A DD
  • LDSS-4826A DD (Spanish)
• LDSS-4826A LP
  • LDSS-4826A LP (Spanish)
• LDSS-4826A BR (Not available online.)

Supplemental Nutrition Assistance Program (SNAP) Authorized Representative Request Form (LDSS-4942)

• LDSS-4942 AD
  • LDSS-4942 AD (Spanish)
• LDSS-4942 DD
  • LDSS-4942 DD (Spanish)
• LDSS-4942 LP
  • LDSS-4942 LP (Spanish)
• LDSS-4942 BR
  • LDSS-4942 BR (Spanish) (Not available online.)

Home Energy Assistance Program (HEAP)

Home Energy Assistance Program (HEAP) Application (LDSS-3421)

• LDSS-3421 AD
  • LDSS-3421 AD (Spanish)
• LDSS-3421 DD
  • LDSS-3421 DD (Spanish)
• LDSS-3421 LP
  • LDSS-3421 LP (Spanish)
• LDSS-3421 BR
  • LDSS-3421 BR (Spanish) (Not available online.)

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 AD
  • LDSS-4148A AD Part 1 of 2
  • LDSS-4148A AD Part 2 of 2
  • LDSS-4148A AD (Spanish)
• LDSS-4148A DD
  • LDSS-4148A DD (Spanish)
• LDSS-4148A LP
  • LDSS-4148A LP (Spanish)
• LDSS-4148A BR (Not available online.)

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

• LDSS-4148B AD
  • LDSS-4148B AD Part 1 of 3
  • LDSS-4148B AD Part 2 of 3
  • LDSS-4148B AD Part 3 of 3
  • LDSS-4148B AD (Spanish)
• LDSS-4148B DD
  • LDSS-4148B DD (Spanish)
• LDSS-4148B LP
  • LDSS-4148B LP (Spanish)
• LDSS-4148B BR (Not available online.)

Insert for LDSS-4148B, What you Should Know About Social Services Programs (LDSS-4148B.1)

• LDSS-4148B.1 AD
  • LDSS-4148B.1 AD (Spanish)
• LDSS-4148B.1 DD
  • LDSS-4148B.1 DD (Spanish)
• LDSS-4148B.1 LP
  • LDSS-4148B.1 LP (Spanish)
• LDSS-4148B.1 BR (Not available online.)
  • LDSS-4148B.1 BR (Spanish) (Not available online.)

Important Changes in the Medicaid Program (Supplement to LDSS-4148A and LDSS-4148B)

• LDSS-4148A and LDSS-4148B Supplement AD
  • LDSS-4148A and LDSS-4148B Supplement AD (Spanish)
• LDSS-4148A and LDSS-4148B Supplement DD
  • LDSS-4148A and LDSS-4148B Supplement DD (Spanish)
• LDSS-4148A and LDSS-4148B Supplement LP
  • LDSS-4148A and LDSS-4148B Supplement LP (Spanish)
• LDSS-4148A and LDSS-4148B Supplement BR (Not available online.)

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

• LDSS-4148C AD
  • LDSS-4148C AD (Spanish)
• LDSS-4148C DD
  • LDSS-4148C DD (Spanish)
• LDSS-4148C LP
  • LDSS-4148C LP (Spanish)
• LDSS-4148C BR (Not available online.)

Accessing Applicant/Recipient Informational Books (LDSS-5084)

• LDSS-5084 AD
  • LDSS-5084 AD (Spanish)
• LDSS-5084 DD
  • LDSS-5084 DD (Spanish)
• LDSS-5084 LP
  • LDSS-5084 LP (Spanish)
• LDSS-5084 BR (Not available online.)
  • LDSS-5084 BR (Spanish) (Not available online.)

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