Dshs Statement Form – Fill Out and Use This PDF

The DSHS Statement form serves as a critical tool for individuals to officially document their shared living situation, including the division of costs for food, rent, and utilities among residents at the same address. It requires detailed information about adults and children living at the residence, specifying how expenses are split to ensure clarity and fairness. To simplify the process of sharing these important details, the form also allows for the attachment of additional pages if necessary. For those looking to streamline their shared living documentation, completing this form is a step in the right direction. Click the button below to start filling out your form.

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Dshs Statement Form PDF Details

In the realm of navigating public assistance and community services, clarity and accuracy in reporting living arrangements and the sharing of household expenses are paramount. The DSHS Statement of Shared Living Arrangement form serves as a crucial tool in this process, offering a structured manner for individuals to detail how costs for essentials like food, rent, and utilities are divided among inhabitants of a single dwelling. This form, necessary for the accurate assessment of eligibility and benefits by the Community Services Office (CSO), requires comprehensive information about each resident, including other adults and children, delineating their relationships, shared responsibilities, and individual contributions towards household expenses. By meticulously detailing costs such as monthly rent, heating or cooling, and other utilities separately from the usual rent, it ensures an accurate representation of one's living conditions. Additionally, the form stands as a legal document where adult members of the household affirm the truthfulness of the provided information under the penalty of perjury, underscoring the seriousness with which these declarations are treated by the Department of Social and Health Services (DSHS).

Question	Answer
Form Name	Dshs Statement Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	wa statement arrangement online, statement of living arrangement pdf, shared arrangement aces printable, dshs statement living

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STATEMENT OF SHARED LIVING ARRANGEMENT

COMMUNITY SERVICES OFFICE (CSO)	TELEPHONE NUMBER

ACES CLIENT IDENTIFICATION NUMBER	DATE

The Statement of Shared Living Arrangement explains how you and the other people living at your address share the costs for food, rent, and utilities. Attach additional pages if needed.

1. CLIENT'S NAME		2. TELEPHONE NUMBER				3. TOTAL NUMBER OF PERSONS
		(	)	-		LIVING AT THIS ADDRESS
		(	)	-

4. STREET ADDRESS	CITY				STATE	ZIP CODE

5. Complete the following information for all other ADULTS (age 18 and over) who live at your address:

			RELATIONSHIP TO ME	SHARES FOOD		COOKS OR EATS
					COST	MEALS WITH ME
NAME	SOCIAL SECURITY NUMBER	BIRTHDATE	(SON, MOTHER, FRIEND,

			ETC.)	YES	NO	YES	NO

6. Complete the following information for all CHILDREN (under 18) who live at your address:

			RELATED TO ME?			RELATED TO ANOTHER ADULT LIVING
						AT THIS ADDRESS?
NAME	SOCIAL SECURITY NUMBER	BIRTHDATE
			YES NO	HOW?	YES NO	IF YES, WHO?	HOW?

7. Expense information

Current monthly rent for your address

DO NOT INCLUDE ANY AMOUNT FOR DEPOSITS, BACK

Do you have heating or cooling costs not included in the rent?

Yes

•Heating costs: Costs to operate a device used to heat living quarters.

•Cooling costs: Costs to operate an air conditioning system or room air conditioner.

•Do not include costs for cooking stoves or ovens; gathering fuel for heating; or fans for cooling.

Do you have other electrical, water, or garbage costs not included in the rent?	Yes	No
Do you have telephone costs not included in the rent?	Yes	No

8. Complete the following to explain how you and the other adults living at your address divide monthly expenses.

On the first line, put the amount you pay for each expense. On the other lines, put the name of the other person and amount they pay for each expense:

				EXPENSES
	NAME			ELECTRICITY, WATER,
		RENT	HEATING/COOLING	GARBAGE	TELEPHONE	OTHER
I Pay		$	$	$	$	$

a.		$	$	$	$	$
b.		$	$	$	$	$
c.		$	$	$	$	$
d.		$	$	$	$	$

All persons 18 and over must sign and date this form below.

I declare, under penalty of perjury, that these statements represent our current shared living arrangements.

CLIENT'S SIGNATURE

DATE

SIGNATURE

DATE

CLIENT'S SIGNATURE

DATE

SIGNATURE

DATE

DSHS 14-393(X) (REV. 01/2000) TRANSLATED

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dshs statement shared arrangement conclusion process described (portion 1)

2. The third stage would be to complete these blank fields: Expense information, Current monthly rent for your, DO NOT INCLUDE ANY AMOUNT FOR, Do you have heating or cooling, Heating costs Costs to operate a, Yes, Do you have other electrical water, Do you have telephone costs not, Yes, Yes, Complete the following to explain, On the first line put the amount, NAME, I Pay, and RENT.

Writing segment 2 in dshs statement shared arrangement

3. The following step will be focused on I declare under penalty of perjury, All persons and over must sign, CLIENTS SIGNATURE, CLIENTS SIGNATURE, DSHS X REV TRANSLATED, DATE, DATE, SIGNATURE, SIGNATURE, DATE, and DATE - fill in all of these fields.

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Dshs Statement Form – Fill Out and Use This PDF

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