Ldss 4992-2026

1. Click ‘Get Form’ to open the ldss 4992 application in the editor.
2. Begin by filling out the 'Applicant Information' section. Enter your first name, middle initial, last name, and the last four digits of your Social Security Number (SSN). Provide your street address, apartment number (if applicable), city, state, zip code, and daytime phone number.
3. Next, move to the 'Household Information' section. List all individuals living in your household. For each person, include their name, SSN, date of birth, and indicate if they are blind or disabled by selecting 'YES' or 'NO'. If there are more than three members in your household, continue listing them on the reverse side of the form.
4. If applicable, answer whether anyone in your household has a medical condition worsened by extreme heat. If yes, ensure you have a note from a physician dated within the last twelve months.
5. Finally, read the certification statement carefully. Sign and date the application to affirm that all information provided is accurate.

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