Social Services

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Dennis J. Nowak
Acting Commissioner
3085 Veterans Memorial Hwy
Ronkonkoma, NY 11779
Phone: (631) 854-9930

Emergency Services (After 4:30 PM & Weekends, Holidays): (631) 854-9100 

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Public Forms

To view all the local Department of Social Services forms, please click on the appropriate link.

For a complete listing of Common Forms and Applications from the NYS Office of Temporary and Disability Assistance as well as the following state forms and applications in languages other than English, please click here.

Please print or download form to your computer.
Follow the instructions on each form and print or type legibly.

Social Services Forms


Social Services Forms




Directory for Public Access to Social Services Programs                                                                   

Spanish Version

Directory for Public Access to Social Services Programs. Telephone directory and available services.


Web Fraud Reporting

Spanish Version

If you believe an individual has received welfare assistance improperly, please take the time to share this information with us.


FOIL Request
Spanish Version
Application for Public Access to Records 2

Child Care Services

OCFS-6025 Application for Child Care

OCFS-6025S Spanish Version
This application may be used if your family is ONLY applying for child care services.  If your family is applying for public assistance or other benefits including child care services, you MUST use the Statewide Common Application (LDSS-2921), which can be found in the State Forms section below.  6
OCFS-6026 Instructions

OCFS-6026S Spanish Version

 How to complete the OCFS-6025 Application for Child Care Assistance  4

Documentation Required for Child Care Eligibility

Spanish Version

List of the types of documentation you can submit as proof of identity, address, legal residence in U.S., income, etc.


CCB-6010-002 Verification of Residence

CCB-6010-002 Spanish Version

Have your landlord or other professional person who knows you and your family complete this form verifying your residency and household composition.


CCB-6010-003 Absent Parent Information Form

CCB-6010-003 Spanish Version

Only complete this form if the parent(s) of any child(ren) in need of child care is(are) NOT in the household.  Fill out a separate section for EACH parent that is absent from the household.  Attach additional pages if needed.


CCB-6010-004 Confidential Inquiry on Employment

CCB-6010-004 Spanish Version

Each parent who is working must have their employer complete this form (OR submit a written statement) verifying the days & hours usually worked and wages earned.  If you are working more than one job, a separate form (or written statement) must be completed for each job.  Twelve (12) weeks of pay stubs must also be submitted.


CCB-6010-005 Self-Employment Worksheet

CCB-6010-005 Spanish Version

Submit this form if you are self-employed.  You must also submit the required supporting documentation (see reverse side of the Self-Employment Worksheet)


CCB-6010-006 School/Vocational Training Verification Form

CCB-6010-006 Spanish Version

If your reason for needing child care is school or Vocational training attendance, have the school/program complete this form documenting your attendance.  NOTE: You must also be working at least 17.5 hours per week and earning at least minimum wage to qualify for a child care subsidy.  EXCEPTION: Teen parents attending High School are NOT required to be employed.


CCB-6010-007 Child Care Provider Information Sheet

CCB-6010-007 Spanish Version

Use this form to identify the child(ren) in need of a child care subsidy, what days/hours child care is needed, and whether the child(ren) is(are) already in child care or you need to locate a child care provider for your child(ren).


CCB-6010-009 Client Responsibility Notice

CCB-6010-009-S Spanish Version

You are required to read, sign and return this notice acknowledging your responsibility to immediately report to DSS any changes to your employment, income, housing, household composition, child care provider, etc.


CCB-6010-010 Medical Statement in Support of Special Needs Consideration & Definition of Child with Special Needs in Need of Child Care 

CCB-6010-010-S Spanish Version

Have a qualified professional complete this form for each child in need of a child care subsidy who has a diagnosed special need that adversely affects the child's ability to function normally.  Refer to the "Definition of Child with Special Needs in Need of Child Care" that is attached to the form.


CCB-6010-016  Employer Statement

CCB-6010-016 Spanish Version
Employee Earnings Paid in Cash form for Employer

CCB-6010-019 Special Needs Rate Application

CCB-6010-019 Spanish Version
Application for additional funding for a special needs child

 Client Benefit Services

Housing Package forms English and Spanish Housing Package Forms for Tenant, Broker, Landlord


Hospital Homeless Discharge Referral Form

Spanish Version

For Hospitals and Medical Facilities only  3
Reimbursable Cost Manual for Not-For-Profit Shelters

This manual explains what costs the County of Suffolk will accept and not accept for reimbursement under the Emergency Homeless Shelter Program.  (revised August 2016) 


LDSS 4530 Assignment of Wage Local Address

LDSS 4530-S Spanish Version

Assignment of Wages Local Address 


SCO 221 Housing Verification

SCO 221-S Spanish Version

Housing Verification


SCO 2232-C Consent for Verification of Info.

(contains both English and Spanish versions)

Consent for Verification of Information


SCO 227 Verification of school attendance

SCO 227-S Spanish Version

Verification of school attendance 


SCO 2395 Shelter Supplement Application

Shelter Supplement Application 


SCO 2565 Shelter Arrears Breakdown

SCO 2565S Spanish Version

Shelter Arrears Breakdown


SCO IM 206 Confidential Employment Inquiry
SCO IM 206S Spanish Version

Confidential Employment Inquiry


Medicaid Services

DOH-4287 NOA Continuing your MED-FHP

DOH-4287 SP Spanish Version

Continuing your Medicaid or Family Health Plus Benefits


DOH-4443 Financial Maintenance

DOH-4443 SP Spanish Version

Financial Maintenance form for listing monthly expenses


DOH-5017 Verification Of Employment OHIP
DOH-5017 SP Spanish Version
Verification of Employment


DOH-5018 Self-Declaration Of Income OHIP

DOH-5018 SP Spanish Version

Self-Declaration of Income



New York State Forms

New York State Forms

Form Description Pages
LDSS-2921 Application for Public Assistance - Medical Assistance - SNAP - Services

Spanish Version

Common Instrument that must be completed by applicants for programs administered by NY State Family and Children Services and the NY State Department of Health.


How To Complete the Social Services Application

Spanish Version

Companion Instructions to the DSS 2921



LDSS-4148A SP Spanish Version
What You Should Know About Your Rights and Responsibilities (when applying for or receiving benefits)



LDSS-4148B SP Spanish Version
What You Should Know About Social Services Programs- Q & A



LDSS-4148C SP Spanish Version
 What You Should Know If You Have An Emergency



DOH-4220 Access New York Health Care Application

DOH-4220 Spanish Version

This application is to be used to apply for Children's Medicaid, Child Health Plus, Family Health Plus, Medicaid, Prenatal Care Assistance Program (PCAP), and Women, Infants and Children (WIC) nutritional programs. Based upon the information you provide, you will be told which program you and/or your child(ren) are eligible for. If the applicant is disabled, age 65 or older, or in receipt of Nursing Home care, they must complete DOH-4495a (Supplement A).  In addition to the Medicaid application DOH-4220 above, Access NY Supplement A is required for persons applying for Medicaid who are disabled or age 65 or older in receipt of Nursing Home care.


DOH-4282 Family Planning Benefit Program Application

DOH-4282 Spanish Version

This application is to be completed for the Family Planning Benefit Program (FPBP).  FPBP is a program for New Yorkers who need family planning services, but may not be able to afford them.  It is intended to increase access to family planning services and to enable individuals of childbearing age to prevent or reduce the incidence of unintentional pregnancies.


DOH-4328 Medicare Savings Program Application
DOH-4328 Spanish Version

This application is to be completed when applying for Medicare Savings Program (MSP) only – not Medicaid.  The MSP program pays the Medicare Part B premium and, for eligible individuals, the coinsurance and deductible payments.


Child Support Enforcement Bureau
LDSS-4882 Information about Child Support Services

Spanish Version

What you should know about Child Support Services and Application/Referral for Child Support Services.

Client Benefit Services
LDSS-2291 Request for Replacement of Food Purchased with Supplemental Nutrition Assistance Program (SNAP) Benefits
(contains both English and Spanish versions)
SNAP clients utilize this form if SNAP food is destroyed due to natural event or other disaster.
LDSS-3151 Supplemental Nutrition Assistance Program (SNAP) Change Report Form

LDSS-3151 SP Spanish Version
SNAP clients utilize this form to report any changes required under the rules.
LDSS-3174 New York State Recertification Form for Certain Benefits and Services

LDSS-3174 SP Spanish Version
Common Instrument completed by clients to recertify for Public Assistance, Supplemental Nutrition Assistance Program (SNAP), Medicaid and SNAP, and Medicaid and Public Assistance.
PUB-1313 Instructions for Completing the New York State Recertification Form for Certain Benefits and Services

PUB-1313 SP Spanish Version
Companion Instructions to the LDSS-3174


LDSS-4826 SNAP Benefits Application

LDSS-4826 SP Spanish Version

This application can only be used to apply for Supplemental Nutrition Assistance Program (SNAP) Benefits.


LDSS-4826A Companion Instructions 

LDSS-4826A SP Spanish Version
How to Complete the Supplemental Nutrition Assistance Program (SNAP) Application/Recertification and Applicant/Recipient Rights and Responsibilities for SNAP

LDSS-4942 SNAP Authorized Representative Request Form

LDSS-4942 SP Spanish Version

Clients utilize this form to authorize someone to apply for SNAP benefits for them and/or authorize someone to use their SNAP benefit card to buy food for them.