OTHER HOUSEHOLD MEMBERS. Enter Gross Income Under Each Income Type each Household Member Receives and "How Often" the Income is Received by using the following Income Codes: W=Weekly, E=Every 2 Weeks, T=Twice a Month, M=Monthly, Y=Yearly. If No Income, You MUST Mark the "No Income box." DO NOT Leave Blank. Adult's Full Name (Do not repeat names from Section A) MARK "X" If No Income Gross Earnings from Work Paid Before Deductions, Include How All jobs Often? Indicate Pay from Pensions, Income Paid Retirement, Social Security, Source? How VA benefitsOften? Welfare Benefits, Income Paid Child Support, Source? How Alimony Payments Often? Any Other Income, Income Paid Including Source? How Temporary Income Often? Enter Benefit Type: Enter Benefit CalFresh, CalWORKS, Kin-GAP, FDPIR Xxxxxxx, Xxxxxx $ 199.98 W $ 141.65 Pension Y $ 99.99 Child Support M $ 550.00 Rental Income M ① $ $ $ $ ② $ $ $ $ ③ $ $ $ $ ④ $ $ $ $ ⑤ $ $ $ $
OTHER HOUSEHOLD MEMBERS. 1. Spouse/Housemate (name/relationship)
OTHER HOUSEHOLD MEMBERS describe relationship to applicant, e.g., son, daughter, father, mother, friend, etc. on remaining lines (ATTACH ADDITIONAL PAGE IF NECESSARY) IF NO OTHER HOUSEHOLD MEMBERS, record NONE on line below MAIDEN/ALIAS. *Social Service Law 424a requires the collection of a $25.00 fee for certain categories. A certified check, postal or bank money order, teller's check, cashier's check or agency check made payable to "New York State Office of Children and Family Services" in the amount of twenty-five dollars, is to accompany the form. The check also is to include the applicant's name and the agency code. N.B.: a separate check must accompany each form. **Social Service Law 424a, allows local DSS to bill against their reimbursement the charge collected for screening prospective employees. If you have questions, please call the SCR at 000-000-0000. MAIL YOUR COMPLETED LDSS-3370 FORM TO: STATEWIDE CENTRAL REGISTER P.O. BOX 4480, Attention: Service Center Unit ALBANY, N.Y. 12204-0480 TO ORDER A SUPPLY OF LDSS-3370 FORMS: Please access the (OCFS-4627) Request for Forms and Publications, from the Intranet: xxxx://xxxx.xxxxx.xxxxxx/xxxxx/xxxxx/XXX/ Internet: xxxx://xxxx.xx.xxx/main/forms/cps/ and mail the completed OCFS-4627 Request for Forms and Publications, to: THE OFFICE OF CHILDREN AND FAMILY SERVICES, RESOURCE DISTRIBUTION CENTER, 00 XXXXXX XXX, XXXXXXXXXX, XX 12144. If you have difficulty accessing a form on either site, you can call the automated forms hotline to order forms at 000-000-0000. Print clearly, All dates must be consecutive. Be sure to associate address histories with particular individuals Previous Street Address City State Zip From To Other Household Members are (please print clearly): SCR Use Only Relationship To Applicant Last Name First Name Sex Date of Birth M/F M D Y
OTHER HOUSEHOLD MEMBERS. Name all others who will be living in the household. Name Relationship
