Apd-26 - Employee Regarding Public Assistance Form
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1APD-26
STATEMENT BY PRESENT OR POTENTIAL NYCPD
EMPLOYEE REGARDING PUBLIC ASSISTANCE
PD 407-0614 (02-09)
Exam No. _________________________ List No. ________________
Candidate’s Name _________________________________________
I hereby acknowledge that I am aware that the receiving of Public Assistance while gainfully
employed, without the knowledge of the Department of Social Services, is a violation of law subject to
criminal prosecution, and disciplinary action by the Police Department.
Therefore, I knowingly certify that with respect to myself and any person for whom I am legally or
morally responsible, Public Assistance:
is now being received
is not now being received
was previously received
was not previously received
Where affirmative answers are given to the above, the following information shall be furnished:
1. The office from which benefits are or have been received:
_________________________________________________________________________________________
2. Approximate benefit period:
From ____________________ To_______________________
3. Department of Social Services Number: ___________________________________________
I further acknowledge that I have been instructed that if Public Assistance is presently being received
by me or by any other person for whom I am legally or morally responsible, or is received after this date, I
am required to obtain from the Department of Social Services written proof of my notification to that agency
of my current employment by the NYC Police Department (if applicable), or my employment by the NYC
Police Department immediately after such employment.
Signature: _______________________________________________________
Name Printed: ____________________________________________________
Employed as/Candidate for: _________________________________________
Today’s Date: _____________________________________________________
ABOVE STATEMENT WITNESSED BY: _______ _________________________________________
Rank/Title
Signature
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