DOCUMENTATION REQUIREMENTS LDSS-2642 (Rev.
LDSS-2642 (Rev. 8/05) To prove this factor, provide
Applicant/Recipient Name Case Name
Date Time of Interview Case Number
LOCAL DISTRICT NAME AND ADDRESS:
You must provide proof of the eligibility factors checked. Your worker must receive this proof no later
than ________________________. If your worker does not receive this proof, your application may be
denied or your assistance may be discontinued. (If you cannot obtain these items by the above date,
call ________________________ to find out what other forms may be used to verify your eligibility.)
To prove this factor, provide:
Eligibility Factor
9z ONE of the following
Identity Photo I.D.
Driver’s license
You must prove who you are. U.S. passport
Naturalization Certificate
Hospital/Doctor’s Records
Adoption paper
Marital Status Marriage/Death certificates
Separation agreement
You must prove if you are married,
divorced, separated, or widowed.
Divorce decree
Social Security records
VA records
Residence Statement from landlord
You must prove where you live.
Current rent receipt or lease
Mortgage records
Household Composition/Size Statement from non-relative Landlord
School records
You must prove who is living with you.
Age Birth certificate
You must prove the age of each person
Baptismal certificate
Hospital records
applying for assistance, where appropriate. Adoption records
Naturalization certificate
Driver’s license
Absent Parent Death certificate
Survivor’s benefits
If the parent of any child in your home is not Hospital records
living with you, you must prove this VA or military records
Divorce papers
Proof of remarriage
Absent Parent Information Pay Stubs
Tax returns
You must provide any information you have: Social Security or VA records
name, address, Social Security Number, birth Monetary determination letters
date, employment ID. cards (health insurance)
Driver’s license or registration
To prove this factor, provide
Eligibility Factor
Social Security Number
(For Temporary Assistance,
Food Stamp Benefits and
Medical Assistance-only, you do
not have to provide proof of
your Social Security Number
(SSN) unless the SSN you give
does not match with SSA’s
records or cannot be verified by
the agency.)
Citizenship or Current Alien
Status - US citizens are eligible
for Temporary Assistance, Food
Stamps and Medical
Assistance. Aliens must be in
satisfactory immigration status
in order to be eligible for
Temporary Assistance, Food
Stamps or Medical Assistance.
Immigration status is not an
eligibility factor for pregnant
9z TWO of the following
women or immigrant children
(If you are applying for Food Stamp applying for Child Health Plus B.
Benefits or Medical Assistance only, Undocumented immigrants and
OR
you need to bring only one form for temporary non-immigrants are
eligible only for the treatment of
each eligibility factor checked.)
Statement from another person
an
condition.
emergency medical
Validated Social Security Number
Birth/Baptismal Certificate Earned Income
From employer
Statement from clergy
Census records
Newspaper notice
Statement from another person
From self-employment
Statement from another person
Current mail
School records
Statements from other persons
Income from rent or
Insurance policy
room/board
Census records
School records
Unearned Income
Statement from another person Child support
Physician statement
Official correspondence from SSA
Unemployment Insurance
Newspaper notice
Insurance company records
benefits (UIB)
Institutional records
Agency case records and burial payment files
Statement from another person
Social Security benefits
(including SSI)
Veteran’s benefits
WORKER NAME
APPLICANT/ RECIPIENT SIGNATURE
one of the following:
Social Security Card
Official correspondence from SSA
A Social Security Number is not
required for aliens who are seeking
Medical Assistance for emergency
treatment only or are Medical
Assistance-only applicants who are
pregnant.
Birth certificate
Baptismal certificate
Hospital records
U.S. passport
Military service records
Naturalization certificate
USCIS documentation
Evidence of continuous U.S.
residence since prior to 1/1/72.
Current wage stubs
Pay envelopes
On letterhead, rate of pay per
hour; hours worked per week;
date of first pay, if new and
employer’s phone number
Contact with employer
Business records
Tax records
Records and related materials
concerning self-employment
earnings and expenses
Current income tax return
Current contribution check
Statement from roomer,
boarder, tenant
Income tax records
Statement from Family Court
Statement from person paying support
Check stubs
Current award certificate
Current benefit check
Official correspondence with
NYS Dept. of Labor
Current award certificate
Current benefit check
Official correspondence from SSA
Current award certificate
Current benefit check
Official correspondence from VA
To prove this factor, provide
Eligibility Factor
Unearned Income (con’t)
Workers’ Compensation
Education grants and loans
Interest/dividends/royalties
Private pension/annuity
Other
Resources
Bank accounts:
checking, savings, retirement
(IRA and Keogh)
Stocks, bonds, certificates
Life Insurance
Burial trust or fund burial plot or
funeral agreement
Income tax refund or earned
income tax credit (EITC)
Real estate other than
Residence
Motor Vehicle
Lump sum payment
Eligibility Factor one of the following:
one of the following:
Other
Award Letter
Check stub
Statement from school
Statement from bank
Award letter Shelter Expenses Current rent receipt
You must prove how much it Current lease
Mortgage book/records
Statement from bank or credit
costs you to live where you do
(You may need to provide Property and school tax records
union
Statement from broker/agent
separate documentation for Landlord statement
Sewer and water bills
each item of shelter expense.)
Homeowner’s insurance records
Medical Assistance does not
require documentation of Fuel bills
shelter expenses. Non-heating utility bills
Current award letter Telephone bills
Current benefit check
Official correspondence from
Medical Bills Copies of medical bills (paid and
unpaid)
source of income
Health Insurance Insurance policy
Statement from household If you or anyone applying has Insurance card
Statement from provider of
Statement from nursing home health insurance coverage
(even if paid for by someone coverage
Medicare card
else), you must prove this.
Current bank records Disabled/Incapacitated Statement from medical
Current credit union records /Pregnant professional verifying pregnancy
If you or anyone living with you and expected date of birth
Stock certificate
is sick or pregnant, you must Statement from medical
professional
provide proof.
Bonds Proof of SSA or SSI benefits for
Statement from financial disability or blindness
institution
Insurance policy
Unpaid Bills Copy of each bill showing amount
Rent, utility owed, period of services and
Statement from insurance
company
provider
Referral Statement from provider of
Drug/Alcohol Treatment Treatment
Bank records
Burial agreement Program
Burial plot deed
Employment Service
Statement from employment
service
Statement from funeral director
Tax Refund Other Expenses/ Court order
Dependent Care Cost Statement from day care center or
Statement from tax office
You must provide proof if you
pay court-ordered support,
other child care provider
Statement from aide or attendant
Deed
Statement from real estate broker child care, recurring loans, or Cancelled checks or receipts
Appraisal/estimate of current value
by broker
for services of a home health
aide or attendant.
Registration (older models) School Attendance School records
Title of ownership (current report card)
Appraisal of current value by
You must prove who is in
school Statement from school/ or Higher
dealer Education Institution
Financing data
Other:
Statement from source of
payment
Lump sum check
DATE TELEPHONE NUMBER
( )
DATE TELEPHONE NUMBER
( )