Form DSHS 14-438 at a glance
What it is: Stop Work, DSHS 14-438: the form your employer completes for the Department of Social and Health Services.
Who signs: By signing here, you give permission to your employer to complete this form for the Department of Social and Health Services. The person in the company signs at SIGN in Section 2.
Where and when to file: DSHS MAILING ADDRESS DSHS PO BOX 11699 TACOMA, WA 98411-9905 DSHS FAX NUMBER 888-338-7410
Section 1: Client, fill out this section before taking it to your job that ended.
A filled-in Form DSHS 14-438 example: a client takes the form to the ex-employer
How to fill out Form DSHS 14-438, box by box
Section 1: Client
Enter the CASE / CLIENT ID NUMBER and the DATE.
Sign at CLIENT'S SIGNATURE DATE and print your name at CLIENT: PLEASE PRINT YOUR NAME HERE.
Name of company / ex-employer
Enter the name of company / ex-employer and the company / ex-employer street address, city, state and zip code.
Section 2: Employment and pay information
Section 2: The person in the company who knows the employment and pay information fills out this section.
Box 1: enter the last date that the employee worked.
Box 2: enter the amount of final paycheck (before taxes) and the date received.
List the amounts (before taxes) and dates received for other paychecks received in the same month as the final paycheck, under AMOUNT RECEIVED (BEFORE TAXES) and DATE RECEIVED.
Why did this job end?
Box 3: mark Lack of work, Job was temporary/seasonal or Laid off.
For On leave (such as leave of absence or parental leave), mark Paid or Unpaid. If paid, enter how much the employee is paid. Enter when the employee is expected to return.
Write after Other.
Severance pay, vacation/sick pay and retirement/pension/401K funds
Boxes 4, 5 and 6: mark yes or No for severance pay, for cash out vacation/sick pay and for withdraw retirement/pension/401K funds. IF YES: enter when it will be received and how much it will be.
Contact: signature, telephone number and position
Sign and date at SIGNATURE DATE, print your name at PRINT YOUR NAME HERE, and enter the TELEPHONE NUMBER and POSITION / TITLE.
Common questions about Form DSHS 14-438
Where do I file it?
DSHS MAILING ADDRESS DSHS PO BOX 11699 TACOMA, WA 98411-9905 DSHS FAX NUMBER 888-338-7410
Sources
[1] Form DSHS 14-438 (REV. 07/2015), Stop Work, Washington State Department of Social and Health Services (the Official source link on this page).