Chemung County, NY · Chemung County
New York State Application for Certain Benefits and Services
This application lets individuals and households apply for public assistance, food benefits, child care, Medicaid with other programs, and certain services through their social services district.
At a glance
- Issued by
- City of Chemung County · Chemung County, Chemung County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- chemungcountyny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this application to request the programs checked in Section 1, including Public Assistance, SNAP, Child Care Assistance, and certain services. Medicaid can be requested on this application only when applying for Public Assistance or SNAP at the same time. It asks about household members, income, work, education, and other circumstances, with signatures and dates required in applicable sections.
Who needs it
Individuals or households seeking the programs listed on the application should complete it and provide information for household members as instructed.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This application is signed without a notary; the certification is signed under penalty of perjury, and the signer dates it.
How to submit this form
- 1
Download The Application
Download the application PDF and review the instruction book referenced on the form.
- 2
Complete Applicable Sections
Select the programs requested and provide the household, income, work, and other information the applicable sections ask for.
- 3
Gather Relevant Information
Review the form’s requested documentation and referral lists to identify information or records relevant to your application.
- 4
Sign And Submit
Sign and date applicable sections, then submit the application to the county department named on the form.
Frequently asked questions
- What programs can I apply for with this application?
- The form lists Public Assistance, SNAP, Child Care Assistance, certain services, and other program combinations. Medicaid is available on this application only when applying for Public Assistance or SNAP at the same time.
- Do I need a notary for the benefits application?
- No. Sign and date the application as instructed. Its certification is signed under penalty of perjury, but the form does not require a notary.
- How do I submit the application?
- Submit it to the county department named on the form; check the county website for current contact details.