Wa Dshs Form PDF Details

In an evolving landscape where numerous individuals and households find themselves in need of assistance, the Washington State Department of Social and Health Services (DSHS) offers a vital gateway through the Application for Cash or Food Assistance (Wa Dshs form). This form is a critical first step for those seeking support, providing a structured means to apply for cash or food benefits. The essence of this document lies not only in its role as an application but also in the comprehensive guidance it offers on how to navigate the process of seeking aid. It outlines clear steps for submission, whether in person, by fax, by mail, or online, ensuring accessibility from various entry points. Essential to the application is the provision of basic information such as name, address, and signature, which can expedite the processing and potentially result in receiving benefits more swiftly or in greater amounts. Intricately, the form goes beyond mere logistics, embedding within its structure adherence to civil rights laws, thereby ensuring non-discrimination and equal opportunity for aid. It highlights the importance of providing Social Security Numbers for applicants, indicating the critical role this information plays in eligibility and fraud prevention processes. Moreover, the document subtly educates applicants on the implications of their immigration status on their eligibility, threading through the complexity of applying for different types of assistance within the same bureaucratic framework. This underscores a multifaceted approach to assistance, where the intersection of civil rights, immigration status, and procedural integrity coalesce, reflecting the nuanced landscape of public assistance programs.

QuestionAnswer
Form NameWa Dshs Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesform dshs wa, wa application, form wa dshs, dshs form application

Form Preview Example

Application for Cash or Food Assistance

If you need help reading or completing thisform, please ask usfor help.

Keep thispage for your records.

How do I apply for cash or food assistance?

You can start the process now by submitting this application in-person at a community services office. The application must have your name, address, and signature or the signature of your authorized representative. You can file your application immediately even if it only contains these three items.

You may get more benefits or get them sooner if you start, complete, and give us your application and any other information we ask for as soon as you can.

You can take your application to a local office. See www.dshs.wa.govfor locations.

Fax your application to 1-888-338-7410

Mail your application to the following: DSHS

CSD-Customer Service Center

PO Box 11699

Tacoma, WA 98411-6699

You can also apply online at www.washingtonconnection.org

For health care coverage you must apply either online at www.wahealthplanfinder.org, by calling 1-855-923-4633, or by using the HCA Application for Health Care Coverage (HCA 18-001).

How soon can I receive help with food and cash assistance?

If you need food assistance right away, fill in Questions 1 through 14 and take this form to your local office.

We decide if you are eligible for food assistance within 7 days if you show proof of your identity and meet one of the following:

Your household will have less than $150 gross income and less than $100 liquid resources this month.

Your household’s income and resources are less than your monthly rent and utilities.

Your household includes a destitute migrant or seasonal farm worker.

Benefitsare issued by the day after we decide you are eligible. We must decide if you are eligible for Food Assistance within 30 days of the date you submit your application. Food assistance usually starts the day we receive your application. If you are submitting your application from an institution, the start date is the date of your release or discharge. Cash assistance usually starts the day we have all the information to decide you are eligible.

Civil Rights

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family / parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1.Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Ave, SW Washington, D.C. 20250-9410;

2.Fax: (202) 690-7442; or

3.Email: program.intake@usda.gov

USDA is an equal opportunity provider, employer, and lender.

DSHS 14-001 (REV. 07/2020)

Page 1

Immigration Status and Social Security Numbers

You may be able to get assistance for some people you live with even if others you live with can’t get help because of immigration status. You must tell us the immigration status of anyone who applies. Alien status of applicant household members may be subject to verification by USCIS (formerly known as INS) through the submission of information from the application to USCIS. Information received from USCIS, based on this submission, may affect eligibility and benefit amounts.

Under Federal Law (45 CFR §205.52, 7 CFR §273.6), You must give us the Social Security Number (SSN) for

anyone you live with who applies for TANF, or food assistance. We may also need SSNs of parents and spouses who live with you but don’t apply.

If you’re applying for Food Assistance and other programs

We must follow the SNAP rules for processing your application. This includes processing the application within time limits, issuing proper notices, and advising you of your administrative rights. We cannot deny your Food Assistance just because your application for other assistance programs was denied.

Privacy and Your Cash and Food Assistance

The Food and Nutrition Act of 2008, as amended, permits the department to collect the information we ask for on the application, including the SSN of each household member. We use SSNs to check identity, verify eligibility, prevent fraud, and collect claims. We exchange information with other agencies to manage our programs and follow the law. Providing the requested information is voluntary. However, failure to provide a SSN or proof of application for a SSN without a good reason will result in the denial of Basic Food assistance to each individual failing to provide a SSN We verify some information with computer matching programs, including the federal Income and Eligibility Verification System (IEVS).

Information reported to the Department of Social and Health Servicesmay affect eligibility for health care coverage administered by the Health Care Authority and the Health Benefit Exchange.

 

 

We use this information to:

 

 

We may give this information to:

 

 

 

 

 

 

 

 

 

Decide who is eligible for our programs.

 

 

Federal and state agencies for official use.

 

 

Collect overpayments.

 

 

Law Enforcement agencies pursuing people who are

 

 

Manage our programs.

 

 

fleeing to avoid the law.

 

 

Make sure we follow the law.

 

 

Private collection agencies to collect food assistance

 

 

 

 

 

overpayments.

 

 

 

 

 

 

 

 

 

 

 

 

Food Assistance Penalty Warning

 

 

 

 

 

 

 

We check with other agenciesthat your information iscorrect. If any information is incorrect, the persons who apply may not get Food Assistance.

Any member who breaksany of the ruleson purpose can be:

Subject to prosecution under other applicable Federal and State laws.

Barred from the SNAP for one year to permanently.

Fined up to $250,000.

Imprisoned up to 20 years.

Barred from SNAP for an additional 18 months if court ordered.

If a court findsyou guilty of:

 

Receiving benefitsin a transaction involving:

You may be:

The sale of a controlled substance...........................Disqualified from two years to permanently.

The sale of firearms, ammunition, or explosives.........Permanently disqualified.

Trafficking benefits of more than $500 combined .......Permanently disqualified.

Residency or identity fraud .....................................Disqualified for 10 years.

DSHS 14-001 (REV. 07/2020)

Page 2

Application for Food and Cash Assistance

Ask us if you need help filling out thisform.

 

 

1. FIRST NAME

MIDDLE INITIAL LAST NAME

SIGNATURE OF APPLICANT OR

 

 

 

 

2. CLIENT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZED REPRESENTATIVE

 

 

 

 

 

(IF KNOWN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. STREET ADDRESS WHERE YOU LIVE

CITY

 

 

STATE

ZIP CODE

 

4. PRIMARY PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CELL

 

 

HOME

 

 

 

MESSAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. MAILING ADDRESS (IF DIFFERENT)

CITY

 

 

STATE

ZIP CODE

 

6. SECONDARY PHONE NUMBER(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CELL

 

 

HOME

 

 

 

MESSAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.I am applying for (check all that apply):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash

 

Food

 

 

 

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. EMAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.I or someone in my household (check all that apply):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are in a domestic violence situation

Have a disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Can’t work because of health problems

Are pregnant; name:

 

 

 

 

 

 

 

 

 

 

 

due date:

 

 

10.

How much money do you expect your household to get this month?

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

How much money does your household have in cash and bank accounts? $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

How much does your household pay for rent or mortgage?

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

What utilities does your household pay for?

 

 

Heating/cooling

Telephone

Other:

 

 

 

 

 

 

 

 

14.

Is anyone in your household a seasonal or migrant farm worker?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

If applying for food assistance, howmany people in your household do you buy and prepare food for?

16.

If applying for child care, what activity do you need care for (check all that apply)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work

 

School

WorkFirst

Basic Food Employment and Training (BFET)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR OFFICE USE ONLY – Household eligible for expedited service:

Yes

No Screener’s Initials:

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

I need an interpreter. I speak:

 

 

 

 

 

or

sign; translate my letters into:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

List everyone in your household even if you are not applying for them (attach additional sheets, if necessary).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

HOW IS THIS

 

 

 

 

 

CHECK IF

 

 

 

 

OPTIONAL FOR NON-APPLICANTS

 

 

 

 

 

 

 

 

 

 

 

 

 

YOU WANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRIBE NAME

 

 

 

 

 

(FIRST,

 

 

 

 

 

 

PERSON

 

 

DATE OF

 

 

 

 

SOCIAL

 

 

 

CHECK

 

 

RACE (SEE

 

 

 

 

 

 

 

 

 

 

GENDER

 

 

 

 

 

 

 

BENEFITS

 

 

 

 

 

 

 

 

 

 

 

(For American

 

 

 

 

MIDDLE,

 

 

 

 

RELATED TO

 

 

BIRTH

 

 

 

 

SECURITY

 

 

 

IF U.S.

 

 

SAMPLES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR THIS

 

 

 

 

 

 

 

 

 

 

Indians, Alaska

 

 

 

 

 

LAST)

 

 

 

 

 

 

YOU?

 

 

 

 

 

 

 

NUMBER

 

 

 

CITIZEN

 

 

 

BELOW)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSON

 

 

 

 

 

 

 

 

 

 

 

 

Natives)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Myself

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

My ethnic background is Hispanic or Latino:

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race and Ethnic background information is voluntary and will not affect eligibility or benefit amounts. This information is used to assure program benefits are distributed without regard to race, color, or national origin. For Food Assistance the USDA requires us to answer for you if no information is provided. Race examples: White, Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, or any combination of races.

DSHS 14-001 (REV. 07/2020)

Page 3

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

I. General Information

1.

In the past 30 days, I received cash or food from another state, tribe, or other source.

Yes

No

 

2.

Someone I’m applying for lives outside Washington State:

Yes

No

Who:

 

 

 

3.

I or someone in my household is a sponsored alien:

Yes

No

Who:

 

 

 

 

 

 

 

 

4.

I or someone in my household age 16 or older is in (check all that apply):

 

High School

 

 

 

a High School Equivalency Program

College

Trade School

 

Who:

 

 

 

5.

Someone is temporarily out of my home:

Yes

No Who:

 

 

 

 

 

 

 

 

 

 

6.

I or someone in my home has served in the U.S. Armed Forces, National Guard, or Reserves or been a

 

 

dependent orspouse of someone who has served:

Yes

No If yes, who:

 

 

 

 

7.I am or someone I’m applying for is fleeing from the law to avoid going to court or jail for a felony crime:

Yes No

8.

I am living in:

My own house or apartment

Group Home

Other:

 

Facility (list type):

 

 

 

 

 

Date entered:

 

9.

I am:

Single

 

Married

Divorced

Separated

Widowed

 

In a Registered Domestic Partnership

 

 

 

 

 

10.I or someone in my home was convicted of trading Food Assistance for drugs after September 22, 1996:

Yes No

11.I or someone in my home was convicted of buying or selling Food Assistance over $500 after September 22, 1996: Yes No

12.I or someone in my home was convicted of trading Food Assistance for guns, ammunitions, or explosives after September 22, 1996: Yes No

13.I or someone in my home was convicted of getting Food Assistance in more than one State after

September 22, 1996:

Yes

No

 

 

 

14. I or someone in my home is: a. On strike: Yes

No b. A boarder:

Yes

No

II. Resources(Attach Proof; For Cash Assistance Only)

A resource is anything you own or are buying that can be sold, traded, or converted into cash or money held by others. A resource does not include personal property such as furniture, or clothing. Examples of resources are:

Cash

Trusts

CDs

Burial funds, prepaid plans

Checking accounts

IRA / 401k

Money market account

Business equipment

Savings accounts

Homes, Land or

Bonds

Livestock

College funds

 

Buildings

Retirement fund

Life insurance

Please list the resources you, your spouse, or anyone you are applying for owns or is buying:

 

RESOURCE

 

WHO OWNS

 

LOCATION

 

VALUE

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

2. I, my spouse, or someone I'm applying for have cars, trucks, vans, boats, RVs, trailers, or other motor vehicles:

YEAR

MAKE (E.G.,

 

 

CHECK IF VEHICLE IS

 

(E.G.,

MODEL (E.G., ESCORT)

CHECK IF LEASED

USED FOR MEDICAL

AMOUNT OWED

FORD)

1980)

 

 

PURPOSES

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

3. I, my spouse, or someone I'm applying for has sold, traded, given away, or transferred a resource in the last

 

 

two years (including trusts, vehicles or life estates):

Yes

No If yes, what:

 

 

when:

 

 

 

 

 

 

 

 

 

 

III. Annuities(Investmentsmade by any household member to receive regular payments

 

 

 

now or in the future.)

 

 

 

 

 

 

 

WHO OWNS THE

COMPANY OR INSTITUTION?

 

AMOUNT OR VALUE

MONTHLY INCOME

DATE PURCHASED

 

 

ANNUITY?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSHS 14-001 (REV. 07/2020)

Page 4

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

IV. Earned Income (Attach Proof)

 

 

1. I, my spouse, or someone I'm applying for had a job that ended in the past 30 days:

 

Yes

 

No

 

 

2. I, my spouse, or someone I'm applying for has income from work:

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

If yes, please complete this section:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHO EARNS THIS INCOME

 

 

 

 

 

 

 

 

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEDUCTIONS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

every:

Hour

 

Week

 

 

EMPLOYER’S NAME AND PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Two weeks

 

 

 

Twice a month

 

Month

 

 

START DATE

 

 

 

 

 

 

 

 

Hours per week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay dates (e.g., 1st and 15th, or every Friday):

 

 

Is this job self-employment?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monthly self-employment expense amount: $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHO EARNS THIS INCOME

 

 

 

 

 

 

 

 

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEDUCTIONS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

every:

Hour

 

Week

 

 

EMPLOYER’S NAME AND PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Two weeks

 

 

 

Twice a month

 

Month

 

 

START DATE

 

 

 

 

 

 

 

 

Hours per week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay dates (e.g., 1st and 15th, or every Friday):

 

 

Is this job self-employment?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monthly self-employment expense amount: $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. Other Income (Attach Proof; Report for All Household Members)

 

 

 

 

 

 

Unemployment benefits

 

 

Supplemental Security income

 

 

Retirement or pension

 

 

Social Security income

 

 

 

(SSI)

 

 

 

Veteran Administration (VA) or

 

 

Tribal income

 

 

Child Support or spousal

 

 

 

 

military benefits

 

 

Gaming income

 

 

 

maintenance

 

 

 

Labor and Industries (L&I)

 

 

Educational benefits (student

 

Railroad benefits

 

 

 

Trusts

 

 

 

 

 

 

 

loans, grants, work - study)

 

 

Rental income

 

 

 

Interests / Dividends

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNEARNED INCOME TYPE

 

 

 

 

 

WHO GETS THE INCOME?

 

 

 

GROSS MONTHLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VI. Monthly Expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RENT

 

MORTGAGE

SPACE RENT

 

HOMEOWNER’S INSURANCE

 

 

PROPERTY TAXES

 

OTHER FEES

 

 

$

 

 

$

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heat (Electric/Gas) Electric (Not Heat)

 

Water Home/Cell Phone

 

 

 

Sewer

Garbage

 

 

 

 

 

Another person or agency, such as subsidized housing, helps me pay either all or part of these expenses:

 

 

Yes

 

No If yes, who:

 

 

 

 

 

 

 

What expense:

 

 

 

 

Amount they pay: $

 

 

 

 

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

 

 

I, my spouse, or someone in my household pay or are supposed to pay (check all that apply):

 

 

 

 

 

 

 

Child or Adult Dependent Care

 

Monthly amount: $

 

Who pays:

 

 

 

 

 

 

 

 

 

 

(including transportation costs)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical bills for persons with

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

disabilities or age 60 +

 

 

Monthly amount: $

 

Who pays:

 

 

 

 

 

 

 

 

 

 

(including transportation costs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and health insurance premiums)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child support (attach proof)

 

 

Monthly amount: $

 

Who pays:

 

 

 

 

 

 

 

If you do not report any of the above listed expenses, we will consider this as a statement by your household that you do not want to receive a deduction for this expense.

DSHS 14-001 (REV. 07/2020)

Page 5

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

VII. Authorized Representative

An Authorized Representative is someone you allow DSHS to talk with about your benefits. You can name

someone, but you do not have to. Do you have an Authorized Representative?

Yes

No

Is this person your legal guardian?

Yes

No

 

You may need to complete the Authorized Representative form (DSHS 14-532).

 

 

NAME

RELATIONSHIP

TELEPHONE NUMBER

MAILING ADDRESS

CITY

STATE

ZIP CODE

Voter Registration

The Department offers voter registration services, including automatic voter registration. Applying to register or declining to register to vote will not affect the servicesor amount of benefitsthat you may receive from 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, we will consider you to have decided not to register to vote at thistime, unless you are eligible for, and do not decline, automatic voter registration.

Unless you checked “No” above, you may be eligible for automatic voter registration. You are eligible for automatic voter registration if you will be at least 18 years old by the next election, you are a citizen of the United States of America, and DSHS has your name, residential and mailing address, date of birth, verification of citizenship information, and your signature attesting to the truth of the information provided on this application.

Do you want to be automatically registered to vote?

Yes

No

If you checked the box marked “Yes,” or do not check either box and you meet automatic voter registration eligibility requirements, DSHS will send your information to the Office of the Secretary of State and you will be automatically registered to vote.

Declaration and Signatures

If applying for cash assistance, all adults(or authorized representatives) in the household must sign.

If applying for food assistance, the applicant (or authorized representative) must sign.

Iunderstand I must:

Give correct information and follow reporting requirements.

Provide proof I am eligible.

Assign certain rights to child support, to the State of Washington when I receive Temporary Assistance for Needy Families (TANF). However, I can ask DSHS not to pursue child support if it would endanger me or my children.

Cooperate with food assistance work requirements.

If I don’t do these things, I may be denied benefits or have to pay them back.

I understand I can be criminally prosecuted if I willfully make a false statement or fail to report something I should report.

I authorize DSHS to contact other persons or agencies when necessary to help me get proof that I am eligible. I have read or had explained to me my rights and responsibilities and received a copy of the Client Rights and Responsibilities, DSHS 14-113. I certify or declare under penalty of perjury under the lawsof the State of

Washington that the information I gave in thisapplication, including the information concerning citizenship and alien statusof the membersapplying for benefits, istrue and correct.

APPLICANT’S SIGNATURE

DATE

PRINTED NAME OF APPLICANT

CITY AND STATE SIGNED

 

 

 

 

OTHER ADULT APPLICANT’S SIGNATURE

DATE

PRINTED NAME OF OTHER ADULT

CITY AND STATE SIGNED

 

 

 

HELPER OR REPRESENTATIVE’SSIGNATURE

DATE

PRINTED NAME OF REPRESENTATIVE CITY AND STATE SIGNED

 

 

 

 

WITNESS’ SIGNATURE IF SIGNED WITH AN “X”

DATE

PRINTED NAME OF WITNESS

 

DSHS 14-001 (REV. 07/2020)

Page 6

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