Form Dshs 14 076 PDF Details

The DSHS 14-076 form serves as a critical tool for individuals and families receiving assistance through various social services in staying compliant with reporting requirements. It is crucial for maintaining eligibility and ensuring that benefits are adjusted based on changes in circumstances, such as income adjustments, changes in household composition, or shifts in living arrangements. By thoroughly completing this form, clients communicate vital information regarding their current situation, including any changes in household income, resources, shelter costs, or even their desire to terminate services. The form also provides an opportunity for individuals to update their voter registration, underscoring the importance of civic engagement among recipients of public assistance. Detailed guidance on how to report changes—ranging from a new job, changes in income levels, adjustments in housing costs or family size, to changes in marital status or health insurance coverage—is outlined, ensuring clarity and compliance. The declaration section at the end emphasizes the importance of accurate reporting under penalty of law, highlighting the serious commitment to integrity and truthfulness in the process. Through this form, the Department of Social and Health Services (DSHS) strives to streamline the reporting process, making it accessible for individuals to maintain their assistance and services, further underlining the form's role in facilitating ongoing support to those in need within the community.

QuestionAnswer
Form NameForm Dshs 14 076
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswashington circumstances search, washington circumstances pdf, change circumstances form, circumstances form online

Form Preview Example

Change of Circumstances

YOUR NAME

CLIENT ID OR SOCIAL SECURITY NUMBER

Read all sections carefully. Check all boxes that apply to your household. Sign, date, and return this form to your local office. If you have any questions, or if you need a postage paid envelope to return this form by mail, contact your local office.

Your Responsibilities: If your household gets cash, Basic Food or medical assistance, you must report changes as described under WAC 388-418-0005, 182-504-0105 and 182-504-0110 based on the benefits you receive. For cash and food assistance programs, you must tell us about these changes by the 10th day of the month after the date the change happened. For medical assistance, you must tell us within 30 days of when the change happened. If you tell us about a change that you do not have to tell us about, we must look at how this impacts your benefits. This may result in fewer benefits, or your benefits may end. For Basic Food, if you voluntarily report a move to a new residence, you must also report your new shelter costs in Section 2, even if you have not been billed for them yet. If you do not give us your new shelter costs, we will use $0. This could cause you to receive fewer benefits.

1.

My address changed.

I moved. Date of move:

 

 

My mailing address changed.

I am homeless.

 

 

 

 

 

My new living address is:

 

 

My new mailing address (if different) is:

 

APARTMENT NUMBER (IF ANY)

APARTMENT NUMBER (IF ANY)

CITY

STATE

ZIP CODE CITY

STATE

ZIP CODE

2.

My shelter costs changed.

For Basic Food, report only if you have an increase or you move to a new residence. Report any other changes in shelter costs at your next mid-certification or eligibility review. Check all that apply.

I am renting.

I am buying.

I am on subsidized housing.

MONTHLY RENT AMOUNT

YOUR SHARE, IF DIFFERENT

MONTHLY MORTGAGE AMOUNT

MONTHLY PAYMENT AMOUNT (LIST

$

$

$

YOUR SHARE ONLY)

 

 

 

$

 

 

 

 

I pay separately for (check all that apply):

Heating/cooling costs I pay: $

per month.

Telephone I pay: $

per month.

Home insurance I pay: $

per month.

Property taxes I pay: $

per month.

3.

Some moved in or out of my home. Check all that apply and indicate the date of the move.

Someone moved INTO my home. Date: List all who moved in (including newborns):

I purchase and prepare meals with my roommates (check box that applies): Yes No

NAME(S)

SEX

RELATIONSHIP

TO ME

SOCIAL SECURITY

NUMBER

I want to include someone in my:

Cash Basic Food Medical assistance

If so, who? List names.

Child care

Someone moved OUT OF my home. Date:

List all who moved out:

NAME(S)

RELATIONSHIP TO ME

I expect the person(s) will move back in with me (check box that applies): Yes No

If so, who? List names:

When do you expect the person(s) to move back in?

4.

My household’s resources changed. I or someone in my household got (check all that apply):

A bank account (check all that apply):

 

Checking

 

Savings

CD’s

Money Market

Amount in account: $

 

 

 

 

 

Date account opened:

 

 

 

 

 

 

 

 

 

 

A vehicle: Year:

 

 

 

Make:

 

 

 

Model:

 

 

 

 

 

Date received:

 

A tax refund: $

 

 

Date received:

 

How much was Earned Income Tax Credit (EITC):

 

 

 

 

 

 

 

 

 

 

 

A lump sum (includes retroactive benefits, settlements, or an inheritance):

 

 

Date received:

Other resources (list):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSHS 14-076 (REV. 09/2015)

5.

My household’s income has changed. Examples of income include earnings or wages from a job or self- employment, unemployment benefits, Social Security, SSI, Labor and Industries (L&I), child support, veterans benefits (VA), gifts, or loans. Check all that apply.

Income or Job STARTED. Date income started:

 

Who’s income started:

Gross amount (before taxes): $

 

 

 

 

per hour

month

Income type:

 

 

Name of employer (if any):

 

Full-time

Part-time

Date(s) person gets income (i.e., 1st and 15th of each month or every Friday):

 

 

 

 

Income or Job ENDED. Date income stopped:

 

 

Who’s income stopped:

Reason why income stopped:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Income or Job INCREASED. Date income increased:

 

 

 

 

Who’s income started:

 

Gross amount (dollar amount before taxes) $

 

 

 

per

hour

month

Income type:

 

 

Name of employer (if any):

 

 

 

 

 

 

If working, is this a change from part-time to full-time?

Yes

No

 

 

 

 

Income or Job DECREASED. Date decreased started:

 

 

 

 

Who’s income started:

 

Gross amount (dollar amount before taxes): $

 

 

 

per

hour

month

Income type:

 

 

Name of employer (if any):

 

 

 

 

 

 

6.

My household has other changes. Check all that apply.

My child care (babysitting) costs changed from: $

 

 

 

/month to $

 

 

 

 

/month.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pregnancy started for:

 

 

 

 

; Expected due date:

 

 

 

 

 

 

.

 

Pregnancy ended for:

 

 

 

 

; Date pregnancy ended:

 

 

 

 

 

.

Child support payments changed from: $

 

 

 

/month to $

 

 

 

 

 

 

/month.

 

 

Who pays:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical expenses increased from: $

 

 

/month to $

 

 

 

 

 

/month.

 

 

Who pays:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status changed for:

 

 

 

Married

Divorced

 

Separated

Widowed

Private medical coverage ended for:

 

 

 

 

 

 

 

; Date coverage ended:

 

 

 

Private medical coverage began for:

 

 

 

 

 

 

 

; Date coverage began:

 

 

 

List insurance company name and phone number if coverage ended or began:

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

OTHER CHANGES (DESCRIBE)

7.

I want to terminate my:

Cash assistance

Basic Food

Medical assistance

Child care

Voter Registration

The Department offers voter registration services as required by the National Voter Registration Act of 1993. Applying to register or declining to register to vote will not affect the services or amount of benefits that you may be provided by 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, you will be considered to have decided not to register to vote at this time.

Declaration and Signature

I state under penalties of perjury that the information I give is true and complete to the best of my knowledge. I understand that if I give false, misleading, or incomplete information, I may be penalized under law (RCW 74.08.055 and RCW 74.08.331). I understand that the information I give is subject to verification and agree to provide the verification. If I can't provide the needed proof, I authorize DSHS to contact other persons or agencies to get the proof on my behalf. My signature on this form means that I have reported all changes that I must report.

SIGNATURE

DATE

TELEPHONE NUMBER

SIGNATURE OTHER ADULT HOUSEHOLD MEMBER OR REPRESENTATIVE

DATE

TELEPHONE NUMBER

DSHS 14-076 (REV. 09/2015)

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