Dshs Review 14 078 Form – Fill Out and Use This PDF

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).

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.

Eligibility Review

Ask us if you need help filling out this form.

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

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

Myself

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

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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

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:

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

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

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:

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:

$

$

$

$

$

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

$

$

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

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)

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

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

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.

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).

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.

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.