Form Dshs 14 467 – Fill Out and Use This PDF

The DSHS 14-467 form, commonly referred to as the Mid-Certification Review form, is a crucial document for individuals and families currently receiving benefits such as cash assistance, Working Family Support, and Basic Food. It outlines the necessary steps and documentation required to continue receiving benefits, highlighting specific conditions and exemptions applicable to different types of aid. For anyone looking to ensure the uninterrupted receipt of their benefits, completing and submitting this form by the specified method—mail, drop-off, or phone—is a step that cannot be overlooked. Fill out the form today by clicking the button below to maintain your benefits without interruption.

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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.

Question	Answer
Form Name	Form Dshs 14 467
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	mid dshs food, dshs mid certification review, wa mid certification review, washington mid certification

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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)

	RELATIONSHIP		DO YOU WANT
NAME	RELATIONSHIP	DATE MOVED IN	BENEFITS FOR THIS		DATE MOVED OUT
NAME	TO YOU	DATE MOVED IN	BENEFITS FOR THIS		DATE MOVED OUT
	TO YOU		PERSON?
			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)

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)

	MAKE	MODEL	MODEL YEAR	CURRENT	AMOUNT	IS THIS A LEASED
OWNER	(EXAMPLES:	(EXAMPLES:	(EXAMPLES:	CURRENT	AMOUNT	IS THIS A LEASED
OWNER	(EXAMPLES:	(EXAMPLES:	(EXAMPLES:	VALUE	OWED	VEHICLE?
	FORD, DODGE)	FOCUS, NEON)	1998, 2004)	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
NAME OF THE WINNER		SOURCE OF THE WIN				(BEFORE TAXES)		DATE RECEIVED
						(BEFORE TAXES)

						$

8. Earnings/ Self-Employment Income
NAME OF	EMPLOYER AND	EMPLOYER	PAY RATE (EXAMPLES:				WEEKLY	DAYS PAID (EXAMPLES:
NAME OF	CONTACT PERSON	EMPLOYER		$10 PER HOUR/			WEEKLY	10TH AND 25TH/EVERY
PERSON	WHO CAN VERIFY	PHONE		$1,200 PER MONTH/			HOURS	OTHER FRIDAY, EVERY
WITH INCOME	WHO CAN VERIFY	NUMBER		$1,200 PER MONTH/			WORKED	OTHER FRIDAY, EVERY
WITH INCOME	YOUR INCOME	NUMBER		$2 PER BUSHEL)			WORKED	TUESDAY/DAILY)
	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)

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

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

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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