Form LDSS-2291 LP "Request for Replacement of Food Purchased With Supplemental Nutrition Assistance Program (Snap) Benefits" - New York (English/Spanish)

What Is Form LDSS-2291 LP?

This is a legal form that was released by the New York State Office of Temporary and Disability Assistance - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the New York State Office of Temporary and Disability Assistance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LDSS-2291 LP by clicking the link below or browse more documents and templates provided by the New York State Office of Temporary and Disability Assistance.

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Download Form LDSS-2291 LP "Request for Replacement of Food Purchased With Supplemental Nutrition Assistance Program (Snap) Benefits" - New York (English/Spanish)

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LDSS-2291 LP (Rev.7/16)
This information is being provided in this alternate
format for informational purposes only. In order to
apply, you must submit an application in written, non-
alternative format.
REQUEST FOR REPLACEMENT OF FOOD
PURCHASED WITH SUPPLEMENTAL
NUTRITION ASSISTANCE PROGRAM (SNAP)
BENEFITS
If you are blind or seriously visually impaired and
need this application/form in an alternative format,
you may request one from your social services
district. For additional information regarding the types
of formats available, contact your social services
district or visit www.otda.ny.gov.
If you are blind or seriously visually impaired, would
you like to receive written notices in an alternative
format?
Yes
No
If Yes, check the type of format you would like:
1
LDSS-2291 LP (Rev.7/16)
This information is being provided in this alternate
format for informational purposes only. In order to
apply, you must submit an application in written, non-
alternative format.
REQUEST FOR REPLACEMENT OF FOOD
PURCHASED WITH SUPPLEMENTAL
NUTRITION ASSISTANCE PROGRAM (SNAP)
BENEFITS
If you are blind or seriously visually impaired and
need this application/form in an alternative format,
you may request one from your social services
district. For additional information regarding the types
of formats available, contact your social services
district or visit www.otda.ny.gov.
If you are blind or seriously visually impaired, would
you like to receive written notices in an alternative
format?
Yes
No
If Yes, check the type of format you would like:
1
Large Print
Data CD
Audio CD
Braille, if you assert that none of the other
alternative formats will be equally effective for you.
If you require another accommodation, please contact
your social services district.
NEW YORK STATE OFFICE OF TEMPORARY
AND DISABILITY ASSISTANCE
CASE NAME ____
COUNTY ____
CASE NUMBER ____
SSN ____
DATE OF BIRTH ____
ADDRESS (including house and Apt number) ____
CITY ____
STATE ____
ZIP ____
PHONE NUMBER ____
I ____, am the head of household or an adult household
member for the above named case and wish to report the
following to the agency representative:
2
My household experienced a loss in the amount of $____
of food purchased with Supplemental Nutrition Assistance
Program (SNAP) benefits, destroyed as a result of:
A power outage
A fire
A flood
Other disaster
Describe: ____
Worker Comments: ____
Client Comments: ____
CERTIFICATION
DO NOT SIGN UNTIL YOU HAVE READ AND
UNDERSTAND THE STATEMENTS BELOW
I am aware that offering a false instrument for filing as
described in Article 175 of the Penal Law is a crime that
may have a maximum penalty of four (4) year's
imprisonment. If I do so, I will be subject to prosecution
under the Civil and Criminal Laws of the United States and
New York State and under the regulations of the New York
State Office of Temporary and Disability Assistance.
I understand I have a right to a fair hearing to contest the
denial or delay of a replacement issuance for my
3
household. Replacements would not be issued pending
the fair hearing decision.
I understand that if I do not sign and return this statement
to the agency within ten (10) days of the date the loss was
reported, the agency will not replace the SNAP benefits.
Signature ____
Date ____
*Please return this completed form to your local
County Social Service Department (SSD) or for NYC
residents visit the HRA website for a list of the local
center closest to you.
LDSS-2291 LP (Rev.7/16)
Tenga en cuenta que las solicitudes se suministran
exclusivamente para propósitos informativos en
formatos alternativos. Por ejemplo, letra grande y
Braille. Si desea hacer una solicitud, usted debe
someter una solicitud por escrito, en un formato no
alternativo. Si usted necesita otra modificación, favor
de comunicarse con su distrito de servicios sociales.
4
PETICIÓN DE REEMPLAZO DE ALIMENTOS
ADQUIRIDOS CON EL SUBSIDIO DEL
PROGRAMA DE ASISTENCIA NUTRICIONAL
SUPLEMENTARIA (SNAP)
Si usted es una persona ciega o tiene un impedimento
visual grave y necesita esta solicitud / formulario en
un formato alterno, lo puede solicitar de su distrito de
servicios sociales. Si desea información adicional
sobre los tipos de formatos disponibles, comuníquese
con su distrito de servicios sociales o ingrese a
www.otda.ny.gov.
Si usted es una persona ciega o tiene un impedimento
visual grave, ¿Le gustaría recibir notificaciones en un
formato alterno?
No
Si contestó «Sí», marque el tipo de formato que
desea:
Letra Grande
CD de Datos
CD Audio
5
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