Wa Dshs Form – Fill Out and Use This PDF

Application for Cash or Food Assistance

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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)

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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)

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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)

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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).

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)

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