NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE
Application/Recertification can ONLY be used to apply or recertify for SNAP
If you are blind or seriously visually impaired and need an application or these instructions in an alternative format, you may request them from your social services district (SSD). The following alternative formats are available:
Applications and instructions are also available for download in large print, data format and audio format from www.otda.ny.gov. Please note that applications are available in audio format and Braille solely for informational purposes. In order to apply, you must submit an application in written, non-alternative format.
If you have any disabilities that prevent you from completing this application and/or from waiting to be interviewed, please notify your SSD. The SSD will make every effort to provide a reasonable accommodation to address your needs.
If you require another accommodation, or need other help completing this application, please contact your SSD. We are committed to assisting and supporting you in a professional and respectful manner.
The LDSS-4826 application can ONLY be used to apply or recertify for SNAP
If you are only applying or recertifying for SNAP you can use the LDSS-4826 application. If you would like to apply for other benefits such as Temporary Assistance, Child Care Assistance, Home Energy Assistance or Medicaid please ask for a different application.
If your household has little or no income or liquid resources, or if your rent and utility expenses are more than your income and liquid resources, or you are a migrant or seasonal farmworker with little or no income or resources when you apply, you may be eligible to get SNAP within 7 calendar days of the date you apply. When a resident of an institution is jointly applying for SSI and SNAP prior to leaving the institution, the recorded filing date of the application is the date of release of the applicant from the institution.
If you live outside of New York City, you can apply on-line at myBenefits.ny.gov, or call or visit the social services district in the county where you live and ask for an application package, which can be mailed to or dropped off at that appropriate office. You can get the address and phone number of the social services district in your county by calling toll free 1-800-342-3009.
If you live in New York City and you are not also applying for Temporary Assistance, you can apply on-line at http://www.nyc.gov/hra, or call or visit any SNAP Office and ask for an application package. You can get the address and phone number by calling 1-718-557-1399 or toll free 1-800-342-3009.
SNAP interviews are usually done over the telephone. If you prefer an in-office interview, you must request one from your social services district.
Be sure to complete each section by PRINTING clearly in blue or black ink.
Do NOT print in the shaded areas.
If you are applying as someone’s representative, please print information about that person, not yourself.
ALTERNATIVE FORMATS: Check “YES” or “NO” to indicate whether you are blind or seriously visually impaired and would like to receive written notices in an alternative format. If "Yes," check the type of format you would like. Alternative formats are available in large print, data CD, audio CD, or Braille, if you assert that none of the other alternative formats are equally effective for you. If you require another accommodation, or need other help completing this application, please contact your SSD.
NAME: PRINT your legal name including your first name, middle initial and last name.
TELEPHONE NUMBER: PRINT your home phone number.
OTHER PHONE: PRINT another phone number where you can be reached, if you have one.
RESIDENCE ADDRESS: PRINT the street, avenue, road, etc., where you now live. PRINT the city you live in. PRINT your zip code.
MAILING ADDRESS: PRINT your mailing address if it is different from your residence.
OTHER NAME: PRINT any maiden names, names from a previous marriage, or other names that any person listed has been known by or now uses.
Check (✓) whether you are applying or recertifying for SNAP.
Check (✓) if you wish to receive notices in Spanish and English or just English.
Sign your name, date, and provide your address (if you have one) ONLY if you want to submit your application without completing the next page at this time to establish your application filing date. You must complete the application process, including the interview and sign on page 8 for us to determine your eligibility.
LIST THE NAMES OF EVERYONE WHO LIVES WITH YOU, EVEN IF THEY ARE NOT APPLYING WITH YOU.
PRINT your full name first. Then PRINT the names of the other people who live with you:
PRINT the Social Security Number (if the individual does not have a SSN, enter “none”), date of birth, marital status and sex for each person applying.
Check (✓) Yes or No to tell us who is applying.
For each person in the household, PRINT how they are related to you (for example: wife, son, friend, etc.).
Check (✓) Yes or No if that person buys and/or prepares food with you.
Check (✓) Yes or No to indicate if each person applying is Hispanic or Latino.
Enter Y (Yes) or N (No) for each race *.
Race/Ethnic codes: I – Native American or Alaskan Native, A – Asian, B – Black or African American, P – Native Hawaiian or Pacific Islander, W – White
The provision of this information is voluntary. It will not affect the eligibility of the persons applying or the level of benefits received. The reason for this information is to ensure that program benefits are distributed without regard to race, color or national origin.
Answer all questions in section 4. Be sure to provide the names of individuals who are not U.S. citizens.
List all your income and the income of everyone living with you. PRINT the name of the person receiving the income, the source of income and how often it is received. Income can include: Regular job (wages), income before strike, on-the-job-training, military reserves, national guard, work study, alimony, child support, educational assistance (grants, scholarships, etc.), friends or relatives (other than loans), temporary assistance, pensions or retirement, Supplemental Security Income (SSI), Social Security benefits, veterans benefits, unemployment benefits, worker’s compensation, babysitting, taxi driving, cleaning homes or other buildings, farming/ranching, income from a roomer, income from a boarder or arts and crafts.
NOTE: Foster Care Payments and SNAP – You may choose to include the foster care child or adult in the SNAP household. If you do, any associated foster care payments will be counted as income. All other income or resources of the foster care child also will be counted. If you have any questions about this, make sure to ask your worker.
Be sure to answer all other questions in section 5.
Resources do not affect the eligibility of most households applying for SNAP. However, some resource information is used to determine if you qualify for expedited processing of your application.
Answer all the questions in Section 6 for yourself and everyone who is applying for SNAP. List the dollar ($) amount or value and the name of the person who has the resource. Be sure to list any joint holdings with non-household members. Resources may include any of the following: cash on hand, cash held by others, checking or savings account, savings bonds, individual retirement account, pension plan, individual development account, stocks/bonds, mutual funds, trust fund, money market certificates, buildings, land, rental property, vacation or recreational property or house other than home.
Enter the name of each applying person in the household aged 16 or older, including yourself. For each person, put an “X” in the box in the “Highest Level of Education” section, using the education and training codes shown on the SNAP Application (LDSS-4826). Check only one box per person. If you enter an “X” in the “0” column for a person, (indicating they do not have a high school diploma or a high school equivalency diploma), enter their highest school grade completed in the “Highest School Grade Completed” box). Leave the “Highest School Grade Completed” box blank if the “0” column is not checked for a person in high school or obtaining a high school equivalency diploma. Please identify the primary language spoken for each individual in the SNAP household that is age 16 or older. The primary language is the language the individual speaks most often.
NOTE: The provision of information regarding highest level of education, highest school grade and primary languages spoken is voluntary. It will not affect the eligibility of the persons applying or the level of benefits received. The information is requested to meet federal reporting requirements.
PRINT the amount you pay for rent, mortgage, room and board or other housing. List the dollar ($) amount that you pay for your property taxes and homeowner’s insurance.
If you pay for your heat separately, check (✓) what type of heat you have and fill in the name of the heating company and your account number.
Also, indicate if:
Be sure to answer all other questions in section 8.
Read this section carefully or have someone read it to you.
Note: NY State Law provides for fine or jail, or both, for a person found guilty of obtaining SNAP by hiding the facts or not telling the truth.
I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my annual electricity usage, electricity costs, fuel consumption, fuel type, annual fuel cost and payment history to the Office of Temporary and Disability Assistance and the local Social Services District and the United States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program (LIHEAP) performance measurement.
NON-DISCRIMINATION NOTICE – In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.
Program information may be available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (for example Braille, large print, audio tape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a complainant should complete a form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: http://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (833) 620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistance Secretary for Civil Rights (ASCR) about the nature and date of alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:
This institution is an equal opportunity provider.
If you want someone from outside your household to apply for SNAP benefits or get an authorized representative EBT card to buy the food for you, PRINT their name, address and phone number, unless the authorized representative has been otherwise designated by the household in writing.
Sign your name. If you are an Authorized Representative, both you and a responsible adult household member must sign and date the signature sections on page 8 of the Application/Recertification.
When an Authorized Representative is applying on behalf of a SNAP Household that does not reside in an institution, both the Authorized Representative and the Head of Household or another responsible adult member of the household must sign and date the signature sections on Page 8 of the Application/Recertification.
Use this section to let us know additional information that you think we might need to know.
If you decide you no longer wish to apply for SNAP, sign your name and enter date. You may reapply at any time.
Note: The last page of this application is an application to register to vote. If you would like help filling out the voter registration application form, ask your worker. Applying or declining to register to vote will not affect your eligibility or the amount of assistance that you will be given by this agency.
Information from your application and interview will be entered and stored in the Welfare Management System (WMS), a statewide computer system. This system is used to improve the management of Social Services Programs and to deter fraud.
Additional information regarding your rights and responsibilities is contained in the Client Information Books (LDSS-4148A; LDSS-4148B and LDSS-4148C). These books can be obtained at your social services district, and on-line.
A Fair Hearing is a chance for you to tell an Administrative Law Judge from the New York State Office of Temporary and Disability Assistance why you think the social services district’s decision about your case was wrong. After the Fair Hearing, the State will issue a written decision which will state whether the social services district’s decision was right or wrong. The written decision may order the social services district to correct your case.
If you want to ask for a Fair Hearing for SNAP, call right away because there are time limits. If you wait too long, you may not be able to get a Fair Hearing. If you get a notice about your case and you want to ask for a Fair Hearing, the notice will tell you how much time you have to ask for the Fair Hearing. Be sure to read all of the notice carefully. If your notice tells you that your SNAP benefits have been denied, will be stopped or will be reduced, you may ask for a Fair Hearing within 90 days from the date of the notice. You may ask for a Fair Hearing if you think you are not getting enough SNAP benefits at any time within the certification period.
If you live anywhere in New York State, you may request a Fair Hearing by telephone, fax, online, or by writing to the address below.
Telephone: Statewide toll free request number is 800-342-3334. Please have the notice, if any, with you when you call.
Fax: your Fair Hearing Request to: 518-473-6735
Online: Complete online request form at http://otda.ny.gov/hearings/
In writing: If you received a notice, fill in the supplied space and send a copy of the notice, or write to:
Fair Hearing Section
NYS Office of Temporary and Disability Assistance
Fair Hearings
P.O. Box 1930
Albany, New York 12201-1930 Please keep a copy of any notice for yourself
Walk-In: If you live in New York City you may also make your request in person by walking into the Office of Administrative Hearings, Office of Temporary & Disability Assistance, 14 Boerum Place, Brooklyn, New York
EMERGENCY - If your situation is very serious, the New York State Office of Temporary and Disability Assistance will set up a Fair Hearing for you as soon as possible. When you call or write for a Fair Hearing, be sure to explain that your situation is very serious.
NOTE: For New York City emergency fair hearings only – Call 800-205-0110. Do not use this telephone number for anything except emergencies. Requests that do not involve emergencies will not be taken at this number.
INTERPRETERS – You have the right to an interpreter at no cost to you, if English is not your primary language, or if you are hearing or speech impaired.
AID CONTINUING - If you get a notice telling you that your benefits will be stopped or reduced, and you ask for a Fair Hearing before the effective date on your notice, your SNAP benefits will, in most instances, stay the same ("aid continuing") until the Fair Hearing decision is made. If you do not get a notice about your case, and your benefits are stopped or reduced, at the same time that you ask for a Fair Hearing, you can ask that your SNAP benefits be restored ("aid continuing") until the Fair Hearing decision is made.
However, if you get "aid continuing" and you lose the Fair Hearing, you may have to pay back any benefits that you received as “aid continuing” while waiting for the Fair Hearing decision. If you do not want the SNAP benefits you have been getting to stay the same until the Fair Hearing decision is made, you must tell this to the New York State Office of Temporary and Disability Assistance when you call or write for a Fair Hearing.
The New York State Office of Temporary and Disability Assistance will send you a notice, which tells you when and where the Fair Hearing will be held. To help you get ready for the Fair Hearing, you have the right to look at your case record and get free copies of the forms and papers which will be given to the Administrative Law Judge at the Fair Hearing. You can also get free copies of any other papers in your case record which you think you may need for the Fair Hearing. Usually, you can get these papers before the hearing or at the hearing at the latest. If you ask for any papers related to your hearing, and the social services district does not give them to you before or at the hearing, you should tell the Administrative Law Judge about it.
You should also bring to the Fair Hearing any witnesses who can help you and any information you have such as: Pay stubs, Bills, Receipts, Leases, Doctor’s statements, to help you explain why you think the social services district’s decision is wrong.
You can bring a lawyer, a relative or a friend to the Fair Hearing to help you explain why you think a social services district’s decision about your case is wrong. If you think you need a lawyer to help you with your Fair Hearing, you may be able to get a lawyer at no cost to you by calling your local Legal Aid or Legal Services Office. For the names of other lawyers, call your local Bar Association.
Someone from the social services district will also be at the Fair Hearing to explain the social services district’s decision about your case. You or your representative will be able to question this person and any witnesses from the social services district.
If you cannot go to the Fair Hearing, you can send someone else in your place. If you are sending someone who is not a lawyer to the Fair Hearing, you must give this person a letter to give to the Administrative Law Judge. This letter should tell the Judge that you want this person to take your place at the Fair Hearing. If the Administrative Law Judge decides that your presence is required, and your testimony is necessary, the hearing may be re-scheduled for another day for you to appear. You will be notified of the new day by mail.
NOTE: If you ask, you will be able to get back the money you had to pay for public transportation, child care and other necessary expenses to go to the fair hearing. If no public transportation is available, you may be able to get back the money you had to pay for another type of transportation. If you are unable to use public transportation because of a medical problem, you may be able to get back the money you had to pay for another type of transportation. However, you may be asked to provide medical verification.
Once you apply for SNAP or other help, case records and computer records are kept about your case. Usually, you have the right to look at those records. However, you may not be able to look at all of the records. Your worker can explain the rules to you.
When you write for copies of your computer records, the Personal Privacy Protection Law requires that New York State agencies, send you your records; or tell you why they will not give you your records; or tell you they have your request and they will determine if you are allowed to get your records within five working days of when they get your request letter.
Unless an individual documents to the satisfaction of the social services district that the individual is exempt (not required to participate) from SNAP work requirements (as described below), the individual must:
An individual is exempt from SNAP work requirements if documentation is provided to the satisfaction of the social services official that the individual is:
If an individual fails or refuses to comply with a SNAP work assignment or quits a job, the individual may become ineligible for SNAP benefits. The length of time that the individual is ineligible for SNAP benefits depends on the number of times the individual has been sanctioned for not complying with a work requirement.
An individual who is required to comply with SNAP work requirements, must meet additional SNAP eligibility requirements unless the individual is:
NOTE: Only the individual who meets one or more of the conditions listed above would be exempt from ABAWD requirements. Other ABAWDs in the SNAP household would still be required to comply with ABAWD requirements in order to continue to receive SNAP benefits for more than 3 months in a 36-month period.
Individuals who are not exempt from the Additional Eligibility Requirement listed above are an ABAWD and are only eligible to receive SNAP benefits for three months in a 36 month period unless that individual:
NOTE: The federal ABAWD requirements listed above apply to each ABAWD in the SNAP household.
If the ABAWD is meeting any of the requirements listed above, but has not notified the social services district, the individual should immediately contact the social services district and provide documentation of their participation to avoid becoming ineligible for SNAP benefits after receiving SNAP benefits for 3 months in a 36-month period. If the ABAWD is not participating in work or qualifying activities for at least 80 hours per month and wants to receive SNAP benefits beyond the 3 month limit and is unable to secure paid employment of at least 80 hours a month, the ABAWD should immediately contact the social services district to discuss the work or work programs that are available to permit the ABAWD to meet their federal ABAWD requirement.
In addition, the ABAWD must provide documentation of participation in unpaid work activities on a monthly basis and report to the social services district within 10 days after the end of the month if the ABAWD’s work hours go below 80 hours a month. Failure to comply with these requirements without good cause may result in the ABAWD being ineligible for SNAP benefits.
An individual may also have a good cause reason that prevented the individual from complying with work requirements, working ore participating in ABAWD qualifying activities for at least 80 hours in the month. Good cause is an event or circumstance beyond an individual’s control that prevents an individual from meeting the work requirements including the ABAWD requirement during the month. Good cause examples may include but are not limited to: a temporary illness or a household emergency. An individual is required to provide proof of any good cause or exemption from the work requirements including the ABAWD work rules, when requested by the social services district. Proof of good cause or exemption could include a statement from a medical professional providing the individual’s care.
If an individual believes that they have good cause for not meeting the work requirements including the ABAWD requirements or the individual believes that they should be exempt from the requirements because they meet one of the conditions identified above or live in an area with an approved ABAWD waiver, the individual should immediately contact the social services district and provide supporting documentation. If an ABAWD does not meet the federal ABAWD requirements and loses eligibility for SNAP as a result, the individual may be able to receive SNAP again, if otherwise eligible, and should immediately contact the social services district to discuss what they need to do to regain SNAP eligibility.
If you find out that you are being investigated because your worker thinks you did not tell the truth about your case, you should talk to a lawyer. If you are charged with welfare fraud in criminal court, the court will, if you are eligible, assign a lawyer to represent you at no cost.
As an Applicant/Recipient of SNAP, you are responsible to reschedule a missed interview before the 30th day after the date you applied to avoid losing SNAP.
When you are applying for SNAP, you will be asked to provide proof of certain things. Your worker will advise you of what is needed. Document requirements may vary for different assistance programs. If the social services district already has proof of certain things that do not change such as social security number, you do not need to prove it again.
By having proof of identity and other important documents when you first apply for assistance, you may be able to get help sooner.
If you are dropping off documents at your social services office, ask for a receipt which should include the district name, your name, the date, time, list of each specific document being left, and the name of the worker giving you the receipt.
You must provide the proof that your worker tells you is needed to have your eligibility for SNAP determined. If you have trouble getting the requested proof, make it known to your worker.
Many non-citizens are qualified non-citizens who are eligible for SNAP. Even if you are not, your children may be eligible. SNAP should not affect your immigration status with respect to any USCIS decision regarding your immigration matter.
You may be eligible for SNAP if you are a United States (U.S.) citizen, a non-citizen U.S. national (people born in American Samoa or Swains Island), or a qualified alien. A qualified non- citizen for SNAP eligibility is: