Dshs Request Identicard Form PDF Details

DSHS is requesting that clients who are unable to pick up their identicard in person, submit this form to authorize a designated representative to pick up the card on their behalf. The form must be notarized and include a copy of the representative's photo ID. Representative Pick-up Authorization forms can be downloaded from the DSHS website or requested by calling 1-800-647-4421. Completed forms should be mailed to: DSHS Identification Unit, P.O. Box 45889, Olympia, WA 98504-5889. For more information, please visit our website or call 1-800-647-4421. Thank you!

QuestionAnswer
Form NameDshs Request Identicard Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswa dshs employment verification form, employee dshs work, washington state id voucher, dshs voucher for id

Form Preview Example

DSHS MAILING ADDRESS

 

DSHS, PO BOX 11699, TACOMA WA 98411-9905

Employment Verification

 

 

DSHS PHONE NUMBER

DSHS FAX NUMBER

 

 

888-338-7410

 

 

 

 

CASE / CLIENT ID NUMBER

DATE

Please use blue or black ink and print or type.

Section 1: To be filled out by the client/employee.

I authorize my employer to release information to the Department of Social and Health Services.

EMPLOYEE’S SIGNATURE

SOCIAL SECURITY NUMBER (OPTIONAL)

DATE

Section 2: To be filled out by the employer.

EMPLOYEE’S NAME

EMPLOYER’S NAME

EMPLOYEE’S JOB TITLE

EMPLOYER’S ADDRESS

Is this a new job?

No

Yes

DATE EMPLOYEE STARTED WORK

DATE FIRST CHECK WAS RECEIVED

AVERAGE HOURS PER WEEK

RATE OF PAY OR SALARY (HOURLY, DAILY OR PIECE RATE)

Has job ended? If yes, when:

No why:

Yes

Pay frequency:

Daily

Weekly

Every two weeks

Two times a month

Monthly

Is this job Work Study?

IF YES, PROVIDE VERIFICATION OF TOTAL FINANCIAL

WHEN WILL YOUR POSITION END?

AID AWARD

 

Yes

No

 

 

 

 

 

 

 

Actual gross income (or attach payroll printout) for last three months:

MONTH:

$

MONTH:

$

MONTH:

$

Actual gross income for current month and anticipated gross income for next two months:

CURRENT MONTH:

$

MONTH:

$

MONTH:

$

Tips

No

Yes; if yes, how often and how much?

Commissions

No

Yes; if yes, how often and how much?

Bonuses

No

Yes; if yes, how often and how much?

Overtime

No

Yes; if yes, how often and how much?

Work schedule (include exact times when possible):

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

Is Health Insurance available?

Yes

No

 

If yes, is employee enrolled in the health plan?

Yes

When does the coverage begin?

 

 

 

What is the employee’s portion of premiums?

 

 

No

EMPLOYER/REPRESENTATIVE’S SIGNATURE

DATE

EMPLOYER/REPRESENTATIVE’S PRINTED NAME AND TITLE

PHONE NUMBER

DSHS 14-252(X) (REV. 05/2015)

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How to fill in dshs employment verification form washington step 1

2. Soon after the prior part is filled out, go on to type in the suitable details in these - Is this job Work Study, Yes, IF YES PROVIDE VERIFICATION OF, WHEN WILL YOUR POSITION END, Actual gross income or attach, MONTH, MONTH, Actual gross income for current, MONTH, MONTH, Tips, Commissions, Bonuses, Overtime, and Yes if yes how often and how much.

dshs employment verification form washington conclusion process explained (step 2)

3. Throughout this part, examine When does the coverage begin, What is the employees portion of, EMPLOYERREPRESENTATIVES SIGNATURE, EMPLOYERREPRESENTATIVES PRINTED, DSHS X REV, DATE, and PHONE NUMBER. Every one of these need to be taken care of with greatest focus on detail.

Step number 3 in completing dshs employment verification form washington

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