Alternative Format Forms

OTDA Home Programs Forms Alternative Format Forms

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)

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

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)

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

Supplemental Nutrition Assistance Program (SNAP) Benefits

SNAP Application/Recertification (LDSS-4826)

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

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

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

Home Energy Assistance Program (HEAP)

The HEAP application is available when HEAP is open.

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)

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

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

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

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

Accessing Applicant/Recipient Informational Books (LDSS-5084)

This page contains links to PDF documents. Download Acrobat Reader to view these documents.

Back to Top

Office of Temporary and Disability Assistance

Home

Programs

Resources

Select a Language