LDSS-2921 Form New York — Filing for a Child-Only Application
What the LDSS-2921 Is
Form LDSS-2921 — Application for Certain Benefits and Services — is New York's combined application for cash assistance, SNAP, Medicaid, and childcare subsidies. It is a 25-plus page state form, and it was designed for all applicants, not specifically for kinship caregivers.
That is the problem. The form does not have a "child-only grant" checkbox or a dedicated non-parent caregiver section. You fill out the same form everyone else does, which means you need to know which parts apply to your situation and which do not.
Where to Get It
The form is freely available from OTDA at otda.ny.gov/programs/applications/. You can also pick it up at any county DSS office or NYC HRA Benefits Access Center.
You do not need to use the paper form. NYC residents can apply online through ACCESS HRA. Outside NYC, myBenefits.ny.gov handles applications for Temporary Assistance, SNAP, and HEAP. Each portal guides you through the programs it handles.
Filing as a Non-Parent Caregiver
When you begin the form — whether on paper or online — make clear that you are a non-parent caregiver applying for assistance for the child. OTDA recommends identifying the application as a non-parent caregiver case; the grant is commonly called a child-only grant.
What this means in practice:
- You provide your identifying information (name, address, ID) because you are the person submitting the application
- You provide the child's information (name, date of birth, Social Security number, income)
- You must provide your own income and resource information on the LDSS-2921, but the district cannot count it when deciding the child's child-only Temporary Assistance eligibility
- You are not applying for assistance for yourself
Answer the application questions accurately. The district cannot count your income or resources for the child's child-only Temporary Assistance eligibility, but other programs on the combined application may use household income. SNAP uses its own household rules, and CCAP considers caregiver household income.
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Documents to Have Ready
The verification requirements are the same regardless of whether you file on paper or online:
| What They Need | Acceptable Documents |
|---|---|
| Child's identity and age | Birth certificate, passport, hospital records |
| Child's Social Security number | SS card or SSA-5028 receipt showing application filed |
| Your identity | NYS driver's license, non-driver ID, passport |
| Your address | Lease, utility bill, mortgage statement |
| Your relationship to the child, if applicable | Birth certificates linking generations, marriage certificates, sworn affidavit |
| Child's income (if any) | SSA award letter, child support order, bank statements |
If the child has no countable income of their own, they may qualify for the full amount allowed under the district's grant schedule.
What Happens After You File
The county must schedule an eligibility interview and process the application within 30 calendar days. During the interview, the caseworker will verify the child's deprivation (parental absence, incapacity, or death) and confirm your relationship.
Watch for the child support question. Filing for cash assistance automatically assigns the child's support rights to the district. You must cooperate unless you claim Good Cause (Form LDSS-2726) due to safety concerns.
The LDSS-2921 also triggers screening for SNAP and Medicaid. You may receive separate determination notices for each program.
If the Application Is Denied
You have the right to request a Fair Hearing through OTDA within 60 days of the denial notice. Aid Continuing applies when an existing benefit is reduced or stopped: request the hearing before the notice's effective date, or within 10 days of its postmark if the notice was delayed, to keep benefits flowing at their current level while the appeal is pending.
Call OTDA at 1-800-342-3334 or file online at otda.ny.gov/hearings.
The LDSS-2921 is the gateway application for kinship benefits in New York, but it only works properly when the district identifies the non-parent caregiver situation correctly. The complete New York kinship benefits guide walks through the form section by section, with the documents and the language you need for the application.
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