Dshs Statement Form PDF Details

DSHS statement form is a document that is used to provide information about an individual’s health insurance coverage. The form can be filled out by the insurance company or the policyholder. The purpose of the DSHS statement form is to ensure that all individuals have access to health care services. The form also helps to ensure that individuals are not charged more than they should be for health care services.

QuestionAnswer
Form NameDshs Statement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswa statement arrangement online, statement of living arrangement pdf, shared arrangement aces printable, dshs statement living

Form Preview Example

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

a.

b.

c.

d.

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?

 

 

 

a.

b.

c.

d.

e.

f.

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

No

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

How to Edit Dshs Statement Form Online for Free

With the online editor for PDFs by FormsPal, you may fill out or alter what is proof of living arrangement dshs form here and now. Our editor is continually evolving to grant the best user experience achievable, and that's because of our dedication to continuous improvement and listening closely to comments from users. With just a few simple steps, you can begin your PDF journey:

Step 1: Press the "Get Form" button at the top of this page to get into our PDF editor.

Step 2: As you start the file editor, you will get the document prepared to be completed. Besides filling out different blank fields, you could also perform some other actions with the PDF, that is adding custom text, changing the initial text, adding images, signing the document, and much more.

In an effort to finalize this PDF form, make sure you type in the information you need in every blank:

1. While filling out the what is proof of living arrangement dshs form, ensure to include all needed blank fields within its relevant section. It will help to speed up the work, which allows your details to be processed promptly and appropriately.

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.

Find out how to prepare dshs statement shared arrangement step 3

It is easy to make an error when filling in the DATE, therefore ensure that you reread it before you decide to submit it.

Step 3: Ensure the details are right and then just click "Done" to progress further. Sign up with FormsPal today and immediately get what is proof of living arrangement dshs form, all set for downloading. Every single change you make is conveniently preserved , allowing you to modify the pdf at a later stage if needed. FormsPal offers risk-free document editor devoid of personal data recording or distributing. Rest assured that your details are safe with us!