Dshs Review 14 078 Form PDF Details

The DSHS form serves as a crucial tool for individuals seeking assistance with cash, food, and other services, ensuring that help is accessible to those who need it most. This form, outlined by the Department of Social and Health Services (DSHS), is designed for individuals applying for or renewing their eligibility for various assistance programs, including cash aid, food support, and specific Washington Apple Health programs. Applicants are encouraged to complete and submit this form at their nearest community services office or online, providing essential information such as name, address, and signature to kickstart the review process. Prompt submission and providing any additional requested information can lead to receiving benefits more quickly or even increase the amount received. The form is not only a gateway to immediate food and cash assistance but also covers important aspects like civil rights, immigration status, social security numbers, and privacy policies, ensuring applicants are treated fairly and information is handled securely. It’s a comprehensive review that touches on eligibility criteria, immediate assistance processes, rights under Federal civil rights law, and important contact information for submitting the form, making it a pivotal step for those in need to access state support services efficiently.

QuestionAnswer
Form NameDshs Review 14 078 Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other names Change of Circumstances - Washington State

Form Preview Example

Eligibility Review

If you need help reading or completing this form, please ask us for help.

Keep this page for your records.

How do I apply for cash or food assistance?

You can start the process now by submitting this review at a community services office. It must have your name, address, and signature or the signature of your authorized representative. You can file your review now even if it only contains these three items.

You may get more benefits or get them sooner if you complete and give us your review and any other information we ask for as soon as you can.

You can take your review to a local office or fax to 1-888-338-7410. See www.dshs.wa.gov for locations.

Mail your review to one of the following:

DSHS

DSHS

CSD-Customer Service Center

Home and Community Services – Long Term Care Services

PO Box 11699

PO Box 45826

Tacoma, WA 98411-6699

Olympia, WA 98504-5826

You can fill out this review online at www.washingtonconnection.org

This Eligibility Review form can only be used to renew coverage for the Washington Apple Health programs listed on this form. For other health care coverage you must apply either online at www.wahealthplanfinder.org, by calling 1-855-923-4633, or by using the HCA Application for Health Care Coverage (HCA 18-001).

How soon can I receive help with food and cash?

If you need food assistance right away, fill in Questions 1 through 14 and take this form to your local office. We decide if you are eligible for food assistance within 7 days if you show proof of your identity and meet eligibility rules.

We issue benefits by the day after we decide you are eligible.

Food assistance usually starts the day we receive your application.

Cash assistance usually starts the day we have all the information to decide you are eligible.

We must decide if you are eligible for Food Assistance within 30 days of the date you submit your application.

If you are submitting your application from an institution, the start date is the date of your release or discharge.

If you’re applying for Food Assistance and other programs:

We must follow the SNAP rules for processing your application. This includes processing the application within time limits, issuing proper notices, and advising you of your administrative rights. We cannot deny your Food Assistance just because your application for other assistance programs was denied.

Civil Rights

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family / parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1.Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Ave, SW

Washington, D.C. 20250-9410;

2.Fax: (202) 690-7442; or

3.Email: program.intake@usda.gov

USDA is an equal opportunity provider, employer, and lender.

DSHS 14-078(X) (REV. 09/2021)

Page 1

Immigration Status and Social Security Numbers

You may get assistance for some people you live with even if others you live with can’t because of their immigration status. You must tell us the immigration status of anyone who applies. Immigration status of household members may be verified by USCIS (formerly known as INS). Information received from USCIS may affect eligibility and benefit amounts. We have health care coverage that may cover some aliens.

Under Federal Law (42 CFR § 435.910, 45 CFR §205.52, 7 CFR §273.6), you must give us the Social Security Number (SSN) for anyone you live with who applies for Washington Apple Health. TANF, or food assistance. We may also need SSNs of parents and spouses who live with you but don’t apply. We have health care coverage for some people who don’t have SSNs.

Citizenship and Identity for Washington Apple Health

U.S. citizens must prove citizenship and identity to receive Washington Apple Health. We can help you obtain the proof. If we need a document that will cost you money, we send for it and pay the cost. We don’t need proof for anyone in your household who receives Medicare, Social Security Disability Insurance (SSDI) based on their own disability or Supplemental Security Income (SSI).

Repaying the State for Medical and Long Term Care

Under Washington State Estate Recovery law (RCW 41.05A.090, RCW 43.20B.080), your estate may need to pay back the costs the State paid for certain types of medical and long-term services and supports you received after you turned age 55. There is no age limit if you received state-only funded services. Estate Recovery begins after your death; payment is due after the death of your surviving spouse, or when your child(ren) turns age 21, unless the child was blind/disabled at your time of death. The State can file a pre-death lien on your real property, at any age, if you live in a nursing home and are unlikely to return home. The State can collect on this lien if you sell or transfer the property, or after your death. If you return home the State removes the lien. For more information, including a list of services subject to Estate Recovery, see Chapter 182-527 WAC.

Privacy and Your Cash and Food Assistance

The Food and Nutrition Act of 2008, lets us collect the information we ask for on the application. Providing the requested information is voluntary, however, failure to provide information without a good reason can result in the denial of Basic Food benefits. We verify some information with computer matching programs, including the federal Income and Eligibility Verification System (IEVS).

We use this information to:

We may give this information to:

• Decide who is eligible for our programs.

• Federal and state agencies for official use.

• Collect overpayments of food assistance.

• Law Enforcement agencies pursuing people who

• Manage our programs.

are fleeing to avoid the law.

• Make sure we follow the law.

• Private collection agencies to collect food

 

assistance overpayments.

Information reported to the Department of Social and Health Services may affect eligibility for health care

coverage administered by the Health Care Authority and the Health Benefit Exchange.

Food Assistance Penalty Warning

We check with other agencies that your information is correct. If any information is incorrect, the persons who apply may not get Food Assistance.

Any member who breaks any of the rules on purpose can be:

• Subject to prosecution under other applicable Federal and State laws.

• Barred from the SNAP for one year to permanently.

• Fined up to $250,000.

• Imprisoned up to 20 years.

• Barred from SNAP for an additional 18 months if court ordered.

If a court finds you guilty of:

 

Receiving benefits in a transaction involving:

You may be:

• The sale of a controlled substance

Disqualified from two years to permanently.

• The sale of firearms, ammunition, or explosives

Permanently disqualified.

• Trafficking benefits of more than $500 combined

Permanently disqualified.

• Residency or identity fraud

Disqualified for 10 years.

DSHS 14-078(X) (REV. 09/2021)

Page 2

Eligibility Review

Ask us if you need help filling out this form.

1.

FIRST NAME MIDDLE INITIAL LAST NAME

 

SIGNATURE OF APPLICANT OR

2.

CLIENT ID NUMBER (IF KNOWN)

 

 

 

 

AUTHORIZED REPRESENTATIVE

 

 

 

 

 

 

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

STREET ADDRESS WHERE YOU LIVE

CITY

 

STATE

ZIP CODE

4.

PRIMARY PHONE NUMBER

 

 

 

 

 

 

 

CELL

HOME

MESSAGE

 

 

 

 

 

 

 

5.

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP CODE

6.

SECONDARY PHONE NUMBER(S)

 

 

 

 

 

 

 

CELL

HOME

MESSAGE

 

 

 

 

 

 

 

 

 

 

8. I am applying for (check all that apply):

 

Cash

Assisted Living / Adult Family Home

7. EMAIL ADDRESS

 

Food

In-Home Long Term Care Services

 

Medicare Savings Program

Nursing Home

 

Hospice

Healthcare / Workers with Disabilities

(HWD)

Health Care coverage for the aged, blind, or disabled

Tailored Supports for Older Adults Services

9.I or someone in my household (check all that apply): Are in a domestic violence situation

Have a disability Can’t work because of health problems

 

Are pregnant; name:

 

 

due date:

 

 

 

 

 

 

 

 

10.

How much money do you expect your household to get this month?

$

 

 

 

 

 

 

11.

How much money does your household have in cash and bank accounts? $

 

 

 

 

 

12.

How much does your household pay for rent or mortgage?

$

 

 

 

 

 

 

13.

What utilities does your household pay for?

Heating/cooling

Telephone

 

Other:

 

14.

Is anyone in your household a seasonal or migrant farm worker?

Yes

No

15.

If applying for food assistance, how many people in your household do you buy and prepare food for?

 

FOR OFFICE USE ONLY – Household eligible for expedited service:

Yes

No Screener’s Initials:

 

Date:

16.

I need an interpreter. I speak:

 

or

sign; translate my letters into:

17. List everyone in your household even if you are not applying for them (attach additional sheets, if necessary).

 

NAME

 

 

 

HOW IS THIS

 

 

 

CHECK IF

 

 

OPTIONAL FOR NON-APPLICANTS

 

 

 

 

 

 

 

 

YOU WANT

 

 

 

 

 

 

 

 

 

 

 

(FIRST,

 

GENDER

 

PERSON

 

DATE OF

 

BENEFITS

 

 

SOCIAL

 

CHECK

 

RACE (SEE

 

TRIBE NAME

 

 

MIDDLE,

 

 

RELATED TO

 

BIRTH

 

 

 

 

 

 

(For American

 

 

 

 

 

 

 

FOR THIS

 

 

SECURITY

 

IF U.S.

 

SAMPLES

 

 

 

LAST)

 

 

 

YOU?

 

 

 

 

 

 

 

 

Indians, Alaska

 

 

 

 

 

 

 

 

PERSON

 

 

NUMBER

 

CITIZEN

 

BELOW)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Natives)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Myself

DSHS 14-078(X)(REV. 09/2021)

Page 3

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

18. My ethnic background is Hispanic or Latino:

Yes

No

Race and Ethnic background information is voluntary and will not affect eligibility or benefit amounts. This information is used to assure program benefits are distributed without regard to race, color, or national origin. . For Food Assistance the USDA requires us to answer for you if no information is provided. Race examples: White, Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, or any combination of races.

I. General Information

1.

In the past 30 days, I received cash or food from another state, tribe, or other source.

Yes

No

2.

Someone I’m applying for lives outside Washington State:

Yes

No

Who:

 

 

3.

I or someone in my household is a sponsored alien:

Yes

No

Who:

 

 

 

 

 

 

4.

I or someone in my household age 16 or older is in (check all that apply):

 

High School

 

 

a High School Equivalency Program

College

 

Trade School

 

Who:

 

 

 

5.Someone is temporarily out of my home: Yes No Who:

6.I or someone in my home has served in the U.S. Armed Forces, National Guard, or Reserves or been a dependent or spouse of someone who has served: Yes No If yes, who:

7.I am or someone I’m applying for is fleeing from the law to avoid going to court or jail for a felony crime:

 

Yes

No

 

 

 

 

 

 

 

 

8.

I am living in:

My own house or apartment

Group Home

Other:

 

Facility (list type):

 

 

 

 

Date entered:

9.

I am:

Single

 

Married

Divorced

Separated

Widowed

 

In a Registered Domestic Partnership

 

 

 

 

 

10.I or someone in my home was convicted of trading Food Assistance for drugs after September 22, 1996:

Yes No

11.I or someone in my home was convicted of buying or selling Food Assistance over $500 after September 22,

1996: Yes No

12.I or someone in my home was convicted of trading Food Assistance for guns, ammunitions, or explosives after

September 22, 1996: Yes No

13.I or someone in my home was convicted of getting Food Assistance in more than one State after

September 22, 1996: Yes No

14.

I or someone in my home is: a. On strike:

Yes

No b. A boarder:

Yes

No

 

 

15.

I or someone in my household has won $3,750 or more in lottery or gambling winnings:

Yes

No

 

If yes, who:

 

 

 

Date received:

 

 

 

 

 

Amount (dollar amount before taxes):

 

 

 

 

 

 

 

 

 

II.Health Insurance Information (Not needed for Basic Food) I, my spouse, or someone in my household:

1.

Plan to enter, are in, or recently left a medical facility (such as a hospital or nursing home) ...

Yes

No

2.

Need help with unpaid medical bills for any of the past three months

Yes

No

3.

Have health insurance:

Yes

No (check all that apply):

Medicare (not Washington Apple Health)

 

Tricare

Long-Term Care Insurance

Indian Health Services

 

 

Other Health Insurance:

III. Resources (Attach Proof; not needed for HWD, or Basic Food)

A resource is anything you own or are buying that can be sold, traded, or converted into cash or money held by others. A resource does not include personal property such as furniture, or clothing. Examples of resources are:

Cash

Trusts

CDs

• Burial funds, prepaid plans

Checking accounts

IRA / 401k

Money Market accounts

Business equipment

Savings accounts

Homes, Land or

Bonds

Livestock

College Funds

 

Buildings

Retirement fund

Life Insurance

DSHS 14-078(X) (REV. 09/2021)

Page 4

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

III.Resources (Attach Proof; not needed for HWD, or Basic Food) (Continued) Please list the resources you, your spouse, or anyone you are applying for owns or is buying:

RESOURCE

WHO OWNS

LOCATION

VALUE

$

$

$

$

$

2.I, my spouse, or someone I'm applying for have cars, trucks, vans, boats, RVs, trailers, or other motor vehicles:

YEAR

MAKE (E.G.,

MODEL (E.G., ESCORT) CHECK IF LEASED

CHECK IF VEHICLE IS USED

AMOUNT OWED

(E.G.,

FORD)

FOR MEDICAL PURPOSES

1980)

 

 

 

 

 

 

$

$

3.I, my spouse, or someone I'm applying for has sold, traded, given away, or transferred a resource in the last

 

five years (including trusts, vehicles, cash or life estates):

Yes

No

 

 

 

If yes, what:

 

 

 

 

 

when:

 

 

 

 

 

 

 

 

 

 

 

IV. Annuities (Investments made by any household member to receive regular payments

 

 

 

 

now or in the future.)

 

 

 

 

 

 

WHO OWNS THE

 

COMPANY OR INSTITUTION?

AMOUNT OR VALUE

MONTHLY INCOME

DATE PURCHASED

 

 

ANNUITY?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

If you, or your spouse, have an interest in an annuity and you accept Washington Apple Health Long Term Care, SSI Related or CN coverage, you must name the State of Washington as a remainder beneficiary of the annuity.

V. Earned Income (Attach Proof)

1. I, my spouse, or someone I'm applying for had a job that ended in the past 30 days:

Yes

No

2.I, my spouse, or someone I'm applying for has income from work: Yes No If yes, please complete this section:

 

WHO EARNS THIS INCOME

 

 

 

 

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

 

 

 

 

 

 

DEDUCTIONS)

 

 

 

 

 

 

 

 

 

$

 

every:

Hour

Week

 

EMPLOYER’S NAME AND PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

Two weeks

Twice a month

Month

 

START DATE

 

 

 

 

 

 

 

 

Hours per week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay dates (e.g., 1st and 15th, or every Friday):

 

Is this job self-employment?

Yes

No

 

 

Monthly self-employment expense amount: $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHO EARNS THIS INCOME

 

 

 

 

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

 

 

 

 

 

 

DEDUCTIONS)

 

 

 

 

 

 

 

 

 

$

 

every:

Hour

Week

 

EMPLOYER’S NAME AND PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

Two weeks

Twice a month

Month

 

START DATE

 

 

 

 

 

 

 

 

 

 

Hours per week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay dates (e.g., 1st and 15th, or every Friday):

 

Is this job self-employment?

Yes

No

 

 

Monthly self-employment expense amount: $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSHS 14-078(X) (REV. 09/2021)

Page 5

APPLICANT’S NAME

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

CLIENT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VI. Other Income (Attach Proof, Report for All Household Members)

 

 

Unemployment benefits

 

Supplemental Security income

 

Retirement or pension

 

 

Social Security income

 

 

(SSI)

 

Veteran Administration (VA) or

Tribal income

 

Child Support or spousal

 

 

military benefits

 

 

Gaming income

 

 

maintenance

 

Labor and Industries (L&I)

 

 

Educational benefits (student

Railroad benefits

 

Trusts

 

 

 

 

 

 

loans, grants, work - study)

 

Rental income

 

Interests / Dividends

 

 

 

 

UNEARNED INCOME TYPE

 

 

 

 

 

 

 

WHO GETS THE INCOME?

 

 

 

 

 

GROSS MONTHLY AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VII. Monthly Expenses

 

 

 

 

 

 

 

 

 

 

RENT

 

MORTGAGE

 

SPACE RENT

 

 

HOMEOWNER’S INSURANCE

 

PROPERTY TAXES

OTHER FEES

 

 

$

 

 

$

 

 

$

 

 

 

 

 

 

$

 

 

 

$

 

 

 

 

$

 

 

 

What utilities does your household pay for separately from rent or mortgage?

 

 

 

 

 

 

 

 

 

 

 

Heat (Electric/Gas) Electric (Not Heat)

 

 

Water Home/Cell Phone

 

 

Sewer

Garbage

 

 

Another person or agency, such as subsidized housing, helps me pay either all or part of these expenses:

Yes

 

No If yes, who:

 

 

 

 

 

 

What expense:

 

 

Amount they pay: $

 

 

 

 

I received a Low Income Home Energy Assistance Act (LIHEAA) payment in the past 12 months.

 

 

I, my spouse, or someone in my household pay or are supposed to pay (check all that apply):

 

 

 

Child or Adult Dependent Care

 

 

 

Monthly amount: $

 

 

Who pays:

 

 

 

(including transportation costs)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical bills for persons with

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

disabilities or age 60 +

 

 

 

 

Monthly amount: $

 

 

Who pays:

 

 

 

(including transportation costs and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

health insurance premiums)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child support (attach proof)

 

 

 

 

Monthly amount: $

 

 

Who pays:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you do not report any of the above listed expenses, we will consider this as a statement by your household that you do not want to receive a deduction for this expense.

VIII. Authorized Representative

An Authorized Representative is someone you allow DSHS to talk with about your benefits. You can name

someone, but you do not have to.

Do you have an Authorized Representative?

Yes

No

 

Is this person your legal guardian?

 

Yes

No

 

Does this person have Power of Attorney?

Yes

No

You may need to complete the Authorized Representative form (DSHS 14-532) if you are renewing your health

care coverage.

 

 

 

 

 

NAME

 

RELATIONSHIP

TELEPHONE NUMBER

 

 

 

 

 

 

 

MAILING ADDRESS

 

CITY

STATE

 

ZIP CODE

 

 

 

 

 

Authorization for Asset Verification

 

 

 

 

 

 

 

 

For Washington Apple Health Aged, Blind or Disabled Medicaid programs only.

I understand the information I provide to apply for or renew assistance will be subject to verification by federal and state officials to determine if it is correct. I authorize the Washington State Health Care Authority (HCA) and Department of Social and Health Services (DSHS) to conduct asset verification to determine my eligibility and to verify the accuracy of my financial information. I understand the HCA and DSHS may investigate and contact any financial institution, state or federal agency, or private database, as part of the asset verification process. I understand this authorization ends when a final adverse decision is made on my application, my eligibility for benefits ends, or if I revoke this authorization at any time by providing HCA or DSHS with written notice. Should I revoke or refuse to provide authorization, I understand that I will not be eligible for any Washington Apple Health Aged, Blind or Disabled Medicaid program.

DSHS 14-078(X) (REV. 09/2021)

Page 6

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

Voter Registration

The Department offers voter registration services, including automatic voter registration. Applying to register or declining to register to vote will not affect the services or amount of benefits that you may receive from this agency. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: Washington State Elections Office PO Box 40229, Olympia, WA 98504- 0229 (1-800-448-4881).

Do you want to register to vote or update your voter registration?

Yes

No

If you do not check either box, we will consider you to have decided not to register to vote at this time, unless you are eligible for, and do not decline, automatic voter registration.

Unless you checked “No” above, you may be eligible for automatic voter registration. You are eligible for automatic voter registration if you will be at least 18 years old by the next election, you are a citizen of the United States of America, and DSHS has your name, residential and mailing address, date of birth, verification of citizenship information, and your signature attesting to the truth of the information provided on this application.

Do you want to be automatically registered to vote?

Yes

No

If you checked the box marked “Yes,” or do not check either box and you meet automatic voter registration eligibility requirements, DSHS will send your information to the Office of the Secretary of State and you will be automatically registered to vote.

Declaration and Signatures

For cash, all adults (or authorized representatives) in the household must sign.

For food assistance or health care coverage the applicant (or authorized representative) must sign.

I understand I must:

Give correct information and follow reporting requirements.

Provide proof I am eligible.

Assign certain rights to child support to the State of Washington when I receive Temporary Assistance for Needy Families (TANF). However, I can ask DSHS not to pursue child support if it would endanger me or my children.

Cooperate with food assistance work requirements.

If I don’t do these things, I may be denied benefits or have to pay them back.

I understand I can be criminally prosecuted if I willfully make a false statement or fail to report something I should report.

I authorize DSHS to contact other persons or agencies when necessary to help me get proof that I am eligible.

For cash and food, I have read or had explained to me my rights and responsibilities and received a copy of the Client Rights and Responsibilities, DSHS 14-113. For health care coverage, I have read or had explained to me my rights and responsibilities and received a copy of the Client Rights and Responsibilities, HCA 18-003, I certify or declare under penalty of perjury under the laws of the State of Washington that the information I gave in this application, including the information concerning citizenship and alien status of the members applying for benefits, is true and correct.

APPLICANT’S SIGNATURE

DATE

PRINTED NAME OF APPLICANT

CITY AND STATE WHERE SIGNED

 

 

 

 

OTHER ADULT APPLICANT’S SIGNATURE

DATE

PRINTED NAME OF OTHER ADULT

CITY AND STATE WHERE SIGNED

 

 

 

 

HELPER OR REPRESENTATIVE’S SIGNATURE

DATE

PRINTED NAME OF REPRESENTATIVE

CITY AND STATE WHERE

 

 

SIGNED

 

 

 

 

 

 

WITNESS’ SIGNATURE IF SIGNED WITH AN “X” DATE

PRINTED NAME OF WITNESS

 

 

 

 

 

 

 

DSHS 14-078(X) (REV. 09/2021)

 

 

 

Page 7

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Complete the We issue benefits by the day, Mail US Department of Agriculture, Office of the Assistant Secretary, Fax or Email, USDA is an equal opportunity, and Page areas with any particulars which may be asked by the system.

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Note the main particulars in FIRST NAME MIDDLE INITIAL LAST, SIGNATURE OF APPLICANT OR, CLIENT ID NUMBER IF KNOWN, STREET ADDRESS WHERE YOU LIVE CITY, STATE, ZIP CODE, PRIMARY PHONE NUMBER, CELL, HOME, MESSAGE, MAILING ADDRESS IF DIFFERENT, CITY, STATE, ZIP CODE, and I am applying for check all that area.

Dshs Review 14 078 Form FIRST NAME MIDDLE INITIAL LAST, SIGNATURE OF APPLICANT OR, CLIENT ID NUMBER IF KNOWN, STREET ADDRESS WHERE YOU LIVE CITY, STATE, ZIP CODE, PRIMARY PHONE NUMBER, CELL, HOME, MESSAGE, MAILING ADDRESS IF DIFFERENT, CITY, STATE, ZIP CODE, and I am applying for check all that fields to fill

The How much money does your, How much does your household pay, What utilities does your, Heatingcooling, Telephone, Other, Is anyone in your household a, Yes, If applying for food assistance, FOR OFFICE USE ONLY Household, Yes, No Screeners Initials, Date, I need an interpreter I speak, and sign translate my letters into field is going to be place to put the rights and obligations of each party.

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End by analyzing the next fields and preparing them accordingly: APPLICANTS NAME, SOCIAL SECURITY NUMBER, CLIENT IDENTIFICATION NUMBER, My ethnic background is Hispanic, Yes, Race and Ethnic background, I General Information, In the past days I received cash, Someone Im applying for lives, I or someone in my household is a, Yes, No Who, No Who, Yes, and High School.

Dshs Review 14 078 Form APPLICANTS NAME, SOCIAL SECURITY NUMBER, CLIENT IDENTIFICATION NUMBER, My ethnic background is Hispanic, Yes, Race and Ethnic background, I General Information, In the past  days I received cash, Someone Im applying for lives, I or someone in my household is a, Yes, No Who, No Who, Yes, and High School fields to complete

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