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Does anyone in your household receive Food Stamps or Medicaid?

Please select the program that you participate and can easily provide proof of eligibility. For example, a picture of your EBT or Medicaid card




(*)
IMPORTANT: Please note that in the State of New York, for applicant’s selecting Medicaid, no proof is required. Eligibility will be defined solely by New York’s Office of Temporary and Disability Assistance (OTDA).

Does anyone in your household receive any of these benefits?


Please select the program that you can easily provide proof of eligibility. For example, a picture or copy of your benefit approval letter.

Select at least one.
(*)
IMPORTANT: Please note that in the State of New York, for applicant’s selecting Medicaid, no proof is required. Eligibility will be defined solely by New York’s Office of Temporary and Disability Assistance (OTDA).

Are you the one receiving the benefit(s) or is it a Child or Dependent?


Please complete your DSHS ID

Please complete your DCN Number

Shipping Info

Address is invalid, common mistakes are: missing or incorrect apartment number, not the correct zip code for this address or the street name is misspelled.
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