DSHS 14-001: Application for Cash or Food Assistance

If you're unable to complete this form today, start the process by submitting your name, address, and signature. You will still need to complete the application before benefits can be approved. A signature on page six is required to complete your application.

Under 1, enter your first name, middle initial and last name.

Under 2, enter your client identification number if known.

Under 3, enter the street address where you live, with city, state and zip code.

Under 4, enter your primary phone number and mark cell, home or message. Under 5, enter your mailing address if different, with city, state and zip code.

Under 6, enter your secondary phone numbers and mark cell, home or message.

Under 7, enter your email address.

Under 8, check all that apply: Cash, Food or Child care. Under 9, check all that apply if you or someone in your household are in a domestic violence situation, have a disability, can't work because of health problems, or are pregnant, and write the name and due date.

Under 10, enter how much money you expect your household to get this month. Under 11, enter how much money your household has in cash and bank accounts. Under 12, enter how much does your household pay for rent or mortgage.

Under 13, check what utilities does your household pay for: Heating/cooling, Telephone or Other.

Under 14, mark Yes or No for: Is anyone in your household a seasonal or migrant farm worker? Under 15, if applying for food assistance, enter how many people in your household you buy and prepare food for. Under 16, if applying for child care, check what activity you need care for.

Under 17, check I need an interpreter, then enter what you speak or sign and what to translate your letters into.

Under 18, list everyone in your household even if you are not applying for them (attach additional sheets, if needed).

For each person, enter the name (first, middle, last), gender, how the person is related to you, and date of birth.

Check if you want benefits for this person, and check if the person is a U.S. citizen.

Social security number, race and tribe name (for American Indians, Alaska Natives) are optional for non-applicants.

Race examples: White, Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, or any combination of races.

Under 19, mark Yes or No for: My ethnic background is Hispanic or Latino. Race and Ethnic background information is voluntary and will not affect eligibility or benefit amounts.

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.

Under 1, list the resources you, your spouse, or anyone you are applying for owns or is buying.

Under 1, mark Yes or No for: I, my spouse, or someone I'm applying for had a job that ended in the past 30 days. Under 2, mark Yes or No for: I, my spouse, or someone I'm applying for has income from work. If yes, complete the section.

For each job, enter who earns this income, the employer's name and phone number, start date, and the gross amount received (dollar amount before deductions), and mark Yes or No for: Is this job self-employment?

For each unearned income type, enter who gets the income and the gross monthly amount.

Check What utilities does your household pay for separately from rent or mortgage: Heat (Electric/Gas), Electric (Not Heat), Water, Home/Cell Phone, Sewer or Garbage.

Check all that apply if you, your spouse, or someone in your household pay or are supposed to pay Child or Adult Dependent Care, Medical bills for persons with disabilities or age 60 +, or Child support (attach proof), and for each enter the monthly amount and who pays. If you do not report any of these listed expenses, DSHS will consider this as a statement by your household that you do not want to receive a deduction for this expense.

An Authorized Representative is someone you allow DSHS to talk with about your benefits. You can name someone, but you do not have to. You may need to complete the Authorized Representative form (DSHS 14-532).

By signing you certify under penalty of perjury under the laws of the State of Washington that the information you gave in this application, including the information concerning citizenship and alien status of the members applying for benefits, is true and correct.

By signing you understand you must give correct information and follow reporting requirements, provide proof you are eligible, and cooperate with food assistance work requirements. If you don't do these things, you may be denied benefits or have to pay them back.

Sign on the Applicant's Signature (Required) line, then enter the date, printed name of applicant, and city and state signed. The Other Adult Applicant's, the Helper or Representative's and the Witness' signature lines (if signed with an “X”) each have signature, date, printed name and city and state signed.

If you need food assistance right away, fill in Questions 1 through 14 and take the form to your local office. DSHS decides 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. Benefits are issued by the day after DSHS decides you are eligible. DSHS 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 DSHS receives 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 DSHS has all the information to decide you are eligible. (checked November 7, 2026)

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).

You can take your application to a local office, fax it to 1-888-338-7410, mail it to DSHS CSD-Customer Service Center, PO Box 11699, Tacoma, WA 98411-6699, or apply online at www.washingtonconnection.org.

Any member who breaks any of the rules on purpose can be subject to prosecution under other applicable Federal and State laws, barred from the SNAP for one year to permanently, imprisoned up to 20 years, barred from SNAP for an additional 18 months if court ordered, and fined up to $250,000 (checked November 7, 2026).