Form Dshs 14 467 PDF Details

The DSHS 14-467 form serves a crucial role in the process of ensuring continued eligibility for various assistance programs administered by the Department of Social and Health Services (DSHS). This Mid-Certification Review form is an essential document that recipients must complete when they are at the midpoint of their certification period for benefits like cash assistance, Working Family Support, and Basic Food. Completing and submitting this form, which can be done through mail, drop-off, or phone, is a mandatory step for beneficiaries to maintain their access to these vital resources. The form encompasses diverse sections, including personal identification, household changes, income and employment details, and more, tailored to assess any changes that might affect a recipient's benefit eligibility. Specific sections such as questions on pregnancy, cash resources, and vehicles highlight the form's comprehensive nature, though some parts may not apply to all programs, reflecting the tailored approach to different types of assistance. The requirement to report new or stopped income, lottery or gambling winnings, and changes in child support, along with detailed sections on living expenses, underscores the thorough review process aimed at ensuring the accuracy and fairness of benefit distribution. Furthermore, the form's inclusion of voter registration services as per the National Voter Registration Act of 1993 and the stern reminders of the legal implications of providing false information stress the importance of honesty and the potential consequences of fraud within these assistance programs.

QuestionAnswer
Form NameForm Dshs 14 467
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmid dshs food, dshs mid certification review, wa mid certification review, washington mid certification

Form Preview Example

Mid-Certification Review

To keep getting benefits, you must complete your mid-certification review by mail, drop-off, or phone.

For Cash:

Answer every question;

Provide proof of income;

Provide proof of all changes; and

Sign and return this review form.

For Working Family Support:

You do not need to answer questions 3, 4, 5 or 12.

You must provide proof of income and hours worked.

For Basic Food:

You do not need to answer questions 3, 4, 5 or 12.

If you receive Basic Food only, you’re not required to provide proof of income for this review. However, you can provide proof of a decrease in income for a possible increase in benefits.

Sign and return this review form.

1. Name, Current Address, and Contact Information

FIRST NAME

LAST NAME

CLIENT IDENTIFICATION (ID) NUMBER

STREET ADDRESS WHERE YOU LIVE

CITY

 

 

STATE

ZIP CODE

 

 

 

 

 

 

MAILING ADDRESS IF DIFFERENT

CITY

 

 

STATE

ZIP CODE

 

 

 

 

 

PRIMARY PHONE NUMBER

 

 

SECONDARY PHONE NUMBER(S)

 

CELL

HOME

MESSAGE

 

CELL

HOME

MESSAGE

 

 

 

 

 

 

 

 

 

2. People Moving In or Out of Your Home

Did anyone move into or out of your home? Yes (tell us more below)

No

 

RELATIONSHIP

 

DO YOU WANT

 

NAME

DATE MOVED IN

BENEFITS FOR THIS

DATE MOVED OUT

TO YOU

 

 

PERSON?

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

3. Pregnancy (Not Needed for Food Assistance)

Did anyone have a change of pregnancy in the last six months? Yes (tell us more below) No

NAME

EXPECTED DUE DATE

PREGNANCY END DATE

4. Cash Resources(Not Needed for Food Assistance)

Do the people in your household have cash resources? Yes (tell us more below)

No

OWNER

 

CHECKING

SAVINGS

STOCKS

BONDS

 

$

 

$

$

$

 

 

 

 

 

 

 

$

 

$

$

$

 

 

 

 

 

 

5. Vehicles(Not Needed for Food Assistance)

Did someone get a vehicle in the last six months?

Yes (tell us more below)

No

 

MAKE

MODEL

MODEL YEAR

CURRENT

AMOUNT

IS THIS A LEASED

OWNER

(EXAMPLES:

(EXAMPLES:

(EXAMPLES:

VALUE

OWED

VEHICLE?

 

FORD, DODGE)

FOCUS, NEON)

1998, 2004)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

6. New Income / Income That HasStopped

Did someone start or stop getting income in the last six months?

Yes (tell us more below) No

(EXAMPLES: NEW JOB / UNEMPLOYMENT COMPENSATION / SOCIAL SECURITY/ L&I BENEFITS/ CHILD SUPPORT)

NAME OF PERSON

 

EMPLOYER OR OTHER

 

DID INCOME START OR

DATE INCOME

DATE INCOME

WITH INCOME

 

SOURCE OF INCOME

 

STOP?

 

STARTED

STOPPED

 

 

 

 

 

 

 

 

 

 

 

 

Start

Stop

 

 

 

 

 

 

 

 

 

 

MID-CERTIFICATION REVIEW

 

Page 1 of 3

 

 

 

DSHS 14-467 (REV. 02/2020)

 

 

 

 

 

 

7. Lottery or Gambling Winnings

 

Did someone win $3,500 or more in lottery or gambling winnings in the last six months?

 

 

Yes (tell us more below)

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF THE WINNER

 

SOURCE OF THE WIN

 

AMOUNT OF THE WIN

 

DATE RECEIVED

 

 

 

(BEFORE TAXES)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Earnings/ Self-Employment Income

 

 

 

 

 

 

 

 

NAME OF

EMPLOYER AND

EMPLOYER

PAY RATE (EXAMPLES:

WEEKLY

DAYS PAID (EXAMPLES:

 

CONTACT PERSON

 

$10 PER HOUR/

10TH AND 25TH/EVERY

 

PERSON

WHO CAN VERIFY

PHONE

 

$1,200 PER MONTH/

HOURS

OTHER FRIDAY, EVERY

 

WITH INCOME

NUMBER

 

WORKED

 

YOUR INCOME

 

$2 PER BUSHEL)

TUESDAY/DAILY)

 

 

 

 

 

 

 

 

 

 

 

$

 

per

 

 

 

$per

If you or someone else in your home is an able-bodied adult without dependents and receive food assistance,

have the work hours fallen below 20 hours per week?

Yes

No

 

 

 

9. Child Support You are Legally Required to Pay

 

 

 

 

 

Did someone have a change in their child support order?

Yes (tell us more below)

No

 

PERSON WHO IS LEGALLY

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT OF SUPPORT

 

OBLIGATED TO PAY CHILD

 

 

 

NAME OF CHILD COVERED IN

 

AMOUNT OF MONTH

 

 

 

 

 

THEY PAY PER MONTH

 

SUPPORT

 

 

 

 

SUPPORT ORDER

 

 

CHILD SUPPORT ORDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Income from Other Sources

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOURCE OF INCOME (EXAMPLES: SOCIAL

 

HOW OFTEN

 

 

 

 

NAME OF PERSON WITH

 

 

 

 

SECURITY / CHILD SUPPORT / L&I

 

RECEIVED

 

AMOUNT RECEIVED

 

INCOME

 

 

 

 

BENEFITS / UNEMPLOYMENT

 

(EXAMPLES:

 

EACH MONTH

 

 

 

 

 

 

COMPENSATION)

 

 

 

WEEKLY/MONTHLY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Rent / Mortgage / Taxesand Mandatory Fees

 

 

 

 

 

 

 

 

 

 

 

LIST MONTHLY AMOUNTS OF THE FOLLOWING EXPENSES

 

LIST YEARLY AMOUNTS OF THE FOLLOWING EXPENSES IF

 

 

 

NOT INCLUDED IN YOUR MORTGAGE OR LEASE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mortgage/rent:

 

$

 

 

 

 

 

Property taxes:

 

$

 

 

 

 

 

Is any part of your mortgage / rent paid by someone

 

Homeowner’s insurance:

$

 

 

 

 

 

else or an agency?

Yes

 

No

 

Association/condo fee:

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How much do they pay:$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How much do you pay: $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Space rent:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Required rental fees:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Utility Costs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

Heat (Electric / Gas)

 

 

 

Electric (Not Heat)

Water

 

Home / Cell Phone

 

Sewer

Garbage

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

MID-CERTIFICATION REVIEW

Page 2 of 3

DSHS 14-467 (REV. 02/2020)

 

13. 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

14. Signature and Date

By signing this form I state the information I gave in this document is true, correct, and complete to the best of my knowledge. I know the information I give on this form may stop or reduce my benefits. I know it is a crime to incorrectly receive cash or food benefits by making a false statement on purpose or failing to report something I know I should report. I understand if I provide information I know is incorrect, I could be criminally prosecuted. I understand penalties for intentionally breaking food assistance rules include disqualification, fines, or imprisonment. I understand if I don’t provide proof of income changes that increase my benefit for cash or food assistance, changes won’t be used to determine my benefits.

SIGNATURE OF HEAD OF HOUSEHOLD OR AUTHORIZED REPRESENTATIVE

DATE

 

 

MID-CERTIFICATION REVIEW

Page 3 of 3

DSHS 14-467 (REV. 02/2020)

 

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