Blank Dshs Template

The DSHS form is an essential document used to review eligibility for cash and food assistance through the Washington State Department of Social and Health Services. This form gathers important information to determine whether individuals or households qualify for various assistance programs, such as food assistance, Medicaid, and Temporary Assistance for Needy Families (TANF). Completing this form accurately and promptly can expedite the process of receiving necessary assistance.

For those who are ready to start the process, please fill out the form by clicking the button below.

Article Guide

The DSHS form is a vital tool for individuals and families seeking assistance with cash and food programs in Washington State. This form helps applicants navigate the eligibility review process, providing essential guidelines on how to apply for benefits. Whether you are looking for cash assistance, food assistance, or healthcare coverage under programs like Washington Apple Health, this form serves as your starting point. It outlines critical information such as what personal details are required—like your name, address, and signature—and how quickly you might receive help. If you are in immediate need, certain sections of the form can be filled out to expedite your application. Various submission methods are available, including online options and local offices, making it easier than ever to seek the support you require. The DSHS form also emphasizes the importance of understanding eligibility requirements, including immigration status and Social Security numbers, ensuring that applicants know what documentation is needed. Additionally, it highlights civil rights protections, assuring that assistance is provided without discrimination, all while reminding applicants of their responsibility to provide accurate information. With clear instructions and the possibility of support, the DSHS form serves as a critical resource for those navigating the complexities of public assistance programs.

Form Sample

Eligibility Review

If you need help reading or completing this form, please ask us for help.

Keep this page for your records.

How do I apply for cash or food assistance?

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

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

•You can take your review to a local office or fax to 1-888-338-7410. See www.dshs.wa.gov for locations.

•Mail your review to one of the following:

DSHS	DSHS
CSD-Customer Service Center	Home and Community Services – Long Term Care Services
PO Box 11699	PO Box 45826
Tacoma, WA 98411-6699	Olympia, WA 98504-5826

•You can fill out this review online at www.washingtonconnection.org

•This Eligibility Review form can only be used to renew coverage for the Washington Apple Health programs listed on this form. For other 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?

•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 eligibility rules.

•We issue benefits by the day after we decide you are eligible.

•Food assistance usually starts the day we receive your application.

•Cash assistance usually starts the day we have all the information to decide you are eligible.

•We must decide if you are eligible for Food Assistance within 30 days of the date you submit your application.

•If you are submitting your application from an institution, the start date is the date of your release or discharge.

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.

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: [email protected]

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

DSHS 14-078(X) (REV. 09/2021)

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Immigration Status and Social Security Numbers

You may get assistance for some people you live with even if others you live with can’t because of their immigration status. You must tell us the immigration status of anyone who applies. Immigration status of household members may be verified by USCIS (formerly known as INS). Information received from USCIS may affect eligibility and benefit amounts. We have health care coverage that may cover some aliens.

Under Federal Law (42 CFR § 435.910, 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 Washington Apple Health. TANF, or food assistance. We may also need SSNs of parents and spouses who live with you but don’t apply. We have health care coverage for some people who don’t have SSNs.

Citizenship and Identity for Washington Apple Health

U.S. citizens must prove citizenship and identity to receive Washington Apple Health. We can help you obtain the proof. If we need a document that will cost you money, we send for it and pay the cost. We don’t need proof for anyone in your household who receives Medicare, Social Security Disability Insurance (SSDI) based on their own disability or Supplemental Security Income (SSI).

Repaying the State for Medical and Long Term Care

Under Washington State Estate Recovery law (RCW 41.05A.090, RCW 43.20B.080), your estate may need to pay back the costs the State paid for certain types of medical and long-term services and supports you received after you turned age 55. There is no age limit if you received state-only funded services. Estate Recovery begins after your death; payment is due after the death of your surviving spouse, or when your child(ren) turns age 21, unless the child was blind/disabled at your time of death. The State can file a pre-death lien on your real property, at any age, if you live in a nursing home and are unlikely to return home. The State can collect on this lien if you sell or transfer the property, or after your death. If you return home the State removes the lien. For more information, including a list of services subject to Estate Recovery, see Chapter 182-527 WAC.

Privacy and Your Cash and Food Assistance

The Food and Nutrition Act of 2008, lets us collect the information we ask for on the application. Providing the requested information is voluntary, however, failure to provide information without a good reason can result in the denial of Basic Food benefits. We verify some information with computer matching programs, including the federal Income and Eligibility Verification System (IEVS).

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 of food assistance.	• Law Enforcement agencies pursuing people who
• Manage our programs.	are fleeing to avoid the law.
• Make sure we follow the law.	• Private collection agencies to collect food
	assistance overpayments.

Information reported to the Department of Social and Health Services may affect eligibility for health care

coverage administered by the Health Care Authority and the Health Benefit Exchange.

Food Assistance Penalty Warning

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

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.

• Fined up to $250,000.

• Imprisoned up to 20 years.

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

If a court finds you guilty of:
Receiving benefits in 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 14-078(X) (REV. 09/2021)

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Eligibility Review

Ask us if you need help filling out this form.

1.	FIRST NAME MIDDLE INITIAL LAST NAME		SIGNATURE OF APPLICANT OR		2.	CLIENT ID NUMBER (IF KNOWN)
			AUTHORIZED REPRESENTATIVE
			(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	Assisted Living / Adult Family Home	7. EMAIL ADDRESS
Cash	Assisted Living / Adult Family Home
Food	In-Home Long Term Care Services
Medicare Savings Program	Nursing Home
Hospice	Healthcare / Workers with Disabilities	(HWD)

Health Care coverage for the aged, blind, or disabled

Tailored Supports for Older Adults Services

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

15.

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

FOR OFFICE USE ONLY – Household eligible for expedited service:

Yes

No Screener’s Initials:

Date:

16.

I need an interpreter. I speak:

sign; translate my letters into:

17. 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

(FIRST,

GENDER

PERSON

DATE OF

BENEFITS

SOCIAL

CHECK

RACE (SEE

TRIBE NAME

MIDDLE,

RELATED TO

BIRTH

(For American

FOR THIS

SECURITY

IF U.S.

SAMPLES

LAST)

YOU?

Indians, Alaska

PERSON

NUMBER

CITIZEN

BELOW)

Natives)

Myself

DSHS 14-078(X)(REV. 09/2021)

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APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

18. My ethnic background is Hispanic or Latino:

Yes

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.

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 or spouse 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
15.	I or someone in my household has won $3,750 or more in lottery or gambling winnings:						Yes	No
	If yes, who:			Date received:
	Amount (dollar amount before taxes):

II.Health Insurance Information (Not needed for Basic Food) I, my spouse, or someone in my household:


1.	Plan to enter, are in, or recently left a medical facility (such as a hospital or nursing home) ...						Yes	No
2.	Need help with unpaid medical bills for any of the past three months						Yes	No
3.	Have health insurance:		Yes	No (check all that apply):		Medicare (not Washington Apple Health)
	Tricare	Long-Term Care Insurance			Indian Health Services

Other Health Insurance:

III. Resources (Attach Proof; not needed for HWD, or Basic Food)

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 accounts	•	Business equipment
•	Savings accounts	•	Homes, Land or	•	Bonds	•	Livestock
•	College Funds		Buildings	•	Retirement fund	•	Life Insurance

DSHS 14-078(X) (REV. 09/2021)

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APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

III.Resources (Attach Proof; not needed for HWD, or Basic Food) (Continued) 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.,	MODEL (E.G., ESCORT) CHECK IF LEASED	CHECK IF VEHICLE IS USED	AMOUNT OWED
(E.G.,
	FORD)		FOR MEDICAL PURPOSES
1980)

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

five years (including trusts, vehicles, cash or life estates):			Yes	No
If yes, what:					when:

IV. Annuities (Investments made 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?	COMPANY OR INSTITUTION?	AMOUNT OR VALUE		MONTHLY INCOME		DATE PURCHASED
ANNUITY?
		$		$
		$		$
		$		$

If you, or your spouse, have an interest in an annuity and you accept Washington Apple Health Long Term Care, SSI Related or CN coverage, you must name the State of Washington as a remainder beneficiary of the annuity.

V. 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

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

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

Monthly self-employment expense amount: $

DSHS 14-078(X) (REV. 09/2021)

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APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

VI. 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

VII. 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.

VIII. 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
	Does this person have Power of Attorney?			Yes	No
You may need to complete the Authorized Representative form (DSHS 14-532) if you are renewing your health
care coverage.
NAME		RELATIONSHIP	TELEPHONE NUMBER

MAILING ADDRESS		CITY	STATE		ZIP CODE

	Authorization for Asset Verification

For Washington Apple Health Aged, Blind or Disabled Medicaid programs only.

I understand the information I provide to apply for or renew assistance will be subject to verification by federal and state officials to determine if it is correct. I authorize the Washington State Health Care Authority (HCA) and Department of Social and Health Services (DSHS) to conduct asset verification to determine my eligibility and to verify the accuracy of my financial information. I understand the HCA and DSHS may investigate and contact any financial institution, state or federal agency, or private database, as part of the asset verification process. I understand this authorization ends when a final adverse decision is made on my application, my eligibility for benefits ends, or if I revoke this authorization at any time by providing HCA or DSHS with written notice. Should I revoke or refuse to provide authorization, I understand that I will not be eligible for any Washington Apple Health Aged, Blind or Disabled Medicaid program.

DSHS 14-078(X) (REV. 09/2021)

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APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

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 services or amount of benefits that 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

If you do not check either box, we will consider you to have decided not to register to vote at this time, 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

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

For cash, all adults (or authorized representatives) in the household must sign.

For food assistance or health care coverage the applicant (or authorized representative) must sign.

I understand 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.

For cash and food, 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. For health care coverage, I have read or had explained to me my rights and responsibilities and received a copy of the Client Rights and Responsibilities, HCA 18-003, I certify or declare under penalty of perjury under the laws of the State of Washington that the information I gave in this application, including the information concerning citizenship and alien status of the members applying for benefits, is true and correct.

APPLICANT’S SIGNATURE	DATE	PRINTED NAME OF APPLICANT	CITY AND STATE WHERE SIGNED

OTHER ADULT APPLICANT’S SIGNATURE	DATE	PRINTED NAME OF OTHER ADULT	CITY AND STATE WHERE SIGNED

HELPER OR REPRESENTATIVE’S SIGNATURE	DATE	PRINTED NAME OF REPRESENTATIVE		CITY AND STATE WHERE
		SIGNED

WITNESS’ SIGNATURE IF SIGNED WITH AN “X” DATE		PRINTED NAME OF WITNESS

DSHS 14-078(X) (REV. 09/2021)				Page 7

⇩ PDF

Document Specifications

Fact Name	Details
Application Process	The DSHS form allows for immediate application for cash or food assistance. You can submit your review at a local community services office even if it's incomplete.
Eligibility Decision Timeline	Eligibility for food assistance is determined within 7 days if you provide proof of identity. For cash assistance, a decision is made once all necessary information is gathered.
Submission Locations	You can submit the form via mail to designated PO Boxes in Tacoma and Olympia, or fax it to a specified number. Local office visits are also an option.
Non-Discrimination Policy	The program adheres to federal civil rights laws, prohibiting discrimination based on various factors including race, gender, and disability. Remedies for violations can vary.
Governing Laws	Federal regulations such as 42 CFR § 435.910 and state laws like RCW 41.05A.090 govern the requirements of the DSHS form and eligibility criteria.

Steps to Filling Out Dshs

After completing the DSHS form, you will be able to submit it for review, which is an essential step in receiving the services you are applying for. It is important to provide accurate information to ensure a smooth process. Follow the steps below to fill out the form correctly.

Write your first name, middle initial, and last name. Sign the form as either the applicant or your authorized representative.
If known, enter your client ID number.
Fill in your street address, city, state, and zip code.
Provide your primary phone number and indicate if it is a cell or home line.
If different, add your mailing address, city, state, and zip code.
List any secondary phone numbers and specify if they are cell or home lines.
Provide your email address.
Indicate the types of assistance you are applying for by checking the relevant boxes.
Check applicable boxes regarding your household situation and provide additional details when necessary.
State your expected income for the month.
Disclose the amount of cash and bank accounts you currently have.
List the amount you pay for rent or mortgage.
Specify what utilities you pay.
State whether anyone in your household is a seasonal or migrant farm worker.
If applying for food assistance, mention how many people you purchase and prepare food for.
Indicate if you need an interpreter and provide your language preference.
List everyone in your household, even if they are not applying for benefits.
Complete sections on health insurance information, resources, annuities, and earned income as applicable.

Once you have filled out the necessary sections, ensure that all information is accurate. You can then submit the form to your local office or through other available channels like online platforms. Taking these steps will guide you through a successful application process.

More About Dshs

What is the DSHS form for?

The DSHS form is used to apply for cash and food assistance programs offered by the Washington State Department of Social and Health Services (DSHS). It helps individuals review their eligibility for various benefits, including Washington Apple Health programs, food assistance, and more.

How do I apply for cash or food assistance using this form?

You can apply by submitting the DSHS form at a community services office. Make sure to include your name, address, and signature, or the signature of someone you have authorized to apply on your behalf. You can submit a completed form on-site, by fax, mail, or even online to expedite the process.

How quickly can I receive assistance after applying?

If you need food assistance right away, complete the specified sections of the form and submit it. Eligibility decisions are typically made within 7 days if you provide proof of identity. Cash assistance can start as soon as all required information is received.

What if I need help completing the form?

If you have trouble reading or completing the DSHS form, do not hesitate to ask for assistance. DSHS representatives can provide help to ensure you fill it out correctly.

Can I apply online?

Yes, you can fill out the form online at www.washingtonconnection.org. This method is often more convenient and can save you time.

What information do I need to provide with the form?

You need to include basic details such as your household income, expenses, and the number of people you buy food for. Also, provide any relevant information about your immigration status and Social Security numbers, if applicable.

What happens if I don’t provide requested information?

While providing information on the form is voluntary, not supplying necessary details can lead to the denial of your benefits. Make sure to answer all questions clearly and completely to avoid issues.

What are the civil rights protections related to the assistance programs?

The programs are governed by federal civil rights laws, which prohibit discrimination based on various factors, including race, color, national origin, and more. Everyone has the right to apply for assistance without facing discrimination.

What is the estate recovery law related to medical and long-term care?

If you received state-funded medical or long-term care services after turning 55, your estate may need to repay these costs after your death. It’s essential to be aware of this, especially if you are considering long-term care options.

How can I report discrimination if I feel my rights were violated?

If you believe you've experienced discrimination, you can file a complaint using the USDA Program Discrimination Complaint Form available online or at any USDA office. You can also contact the USDA's Office of the Assistant Secretary for Civil Rights for further assistance.

Common mistakes

Incomplete Information: Applicants frequently fail to provide all necessary details. For instance, omitting a mailing address or contact numbers can lead to delays in processing applications.
Failure to Sign: Some individuals neglect to sign the form. This step is crucial, as the application requires a signature from the applicant or an authorized representative to be considered valid.
Incorrect Data Entry: Errors often occur when filling in personal information, such as names, Social Security Numbers, or income figures. These inaccuracies may result in complications during the evaluation of eligibility.
Not Submitting on Time: Late submissions are a common mistake. It's essential to send the application promptly to avoid missing out on potential benefits. Benefits are typically effective from the date the application is received, so delays can have significant consequences.

Documents used along the form

In the context of applying for assistance through the Department of Social and Health Services (DSHS), several other forms and documents are often used in conjunction with the DSHS form. These documents help ensure that applicants provide all necessary information regarding their eligibility and needs.

USDA Program Discrimination Complaint Form (AD-3027) - This form enables individuals to report discrimination in USDA programs based on various protected characteristics. It can be completed online or via email and is essential for those who believe they have faced discrimination.
HCA Application for Health Care Coverage (HCA 18-001) - Required for individuals who need to apply for health care coverage outside of Washington Apple Health. This form collects information necessary for evaluating eligibility for health care benefits.
Proof of Identity Document - Individuals must present valid identification to demonstrate their identity and eligibility for assistance. Acceptable documents can include driver’s licenses, state IDs, or passports.
Social Security Numbers (SSN) Documentation - Each applicant must provide Social Security Numbers for themselves and any household members applying for benefits, as this information is crucial for determining eligibility.
Health Insurance Information Form - While not needed for Basic Food assistance, this form collects information regarding any existing health insurance coverage individuals may have, impacting their eligibility for programs.
Resource Declaration Form - Applicants must declare their financial resources, such as cash, bank accounts, or property. This information helps determine their eligibility for cash and food assistance based on available resources.
Earned Income Verification Form - This document details any wages earned by the applicant or household members, supporting the assessment of income levels when applying for assistance programs.

In summary, applicants for DSHS assistance should be prepared to gather and submit a variety of forms. Each document plays a pivotal role in the evaluation process and helps streamline access to needed benefits.

Similar forms

The DSHS form has similarities to the Social Security Administration (SSA) application forms. Both documents gather personal information to determine eligibility for government support. Applicants must provide identification details and information about their household composition. Just like the DSHS form, SSA forms may require the disclosure of financial resources and income to make a comprehensive assessment of the applicant's need for assistance. Additionally, individuals can ask for help in completing their SSA forms, ensuring that no eligible applicant is left without needed support.

Another comparable document is the Supplemental Nutrition Assistance Program (SNAP) application. Similar to the DSHS form, the SNAP application focuses on food assistance eligibility and requires applicants to provide personal details, household information, and income levels. Both forms emphasize the importance of submitting accurate information to avoid penalties. A significant overlap exists in processing timelines, as SNAP aim to determine eligibility within set timeframes, reflecting a commitment to urgent food assistance needs similar to that of the DSHS form.

The Temporary Assistance for Needy Families (TANF) application is also akin to the DSHS form. Both address financial assistance for families in need, collecting data about household income and dependents. Applicants are encouraged to submit all requested information promptly, which might impact the amount and timing of benefits received. The process of verifying social security numbers and immigration status is common to both applications, highlighting their interconnectedness in assessing eligibility for welfare support.

The Medicaid application form shares critical characteristics with the DSHS form, particularly in verifying eligibility for health coverage. Like the DSHS form, applicants must disclose personal information, including their immigration status and social security numbers. Both documents require proof of identity and citizenship. Fast tracking applications for urgent medical needs is also a priority in both forms, ensuring timely assistance for those who meet certain criteria.

Housing assistance applications often align with the requirements outlined in the DSHS form. Both applications seek detailed household income information to assess eligibility for various support programs. They emphasize the importance of timely submission, and housing applications may also include questions regarding domestic situations, giving insights into the reasons for seeking support. Moreover, both forms ensure that individuals are aware of their rights and responsibilities during the application process.

Childcare assistance applications coincide with the DSHS form in that they often request similar data about household composition and financial resources. Both forms aim to certify eligibility based on family income levels, especially for low-income families. Timely processing of applications is crucial for both, as they significantly impact working parents seeking affordable childcare options or other support mechanisms. The requirement for submitting all necessary information is consistent in both scenarios.

The Federal Employee Benefits application has underlying similarities with the DSHS form, particularly regarding the collection of personal demographic information. Both documents focus on benefit entitlement, requiring applicants to disclose details about their employment and income. Additionally, they require verification of household composition to determine eligibility accurately. Applicants often have access to support while filling out both forms, improving submission accuracy and compliance.

Unemployment benefits application forms resemble the DSHS form in that they evaluate applicants' financial needs based on household income and circumstances. Both forms collect detailed information about the applicant’s work history and current financial situation. Timeliness in submitting applications impacts benefit duration and amount, making clarity in the instructions crucial. Applicants may receive guidance during the process, facilitating a smoother experience.

Lastly, the Energy Assistance Program application parallels the DSHS form through its focus on qualifying individuals based on their financial need and household situation. Both require detailed information about income and household composition. The urgency of processing these applications often aligns, particularly for individuals facing immediate financial crises. Clear guidance is available for applicants to ensure proper completion, maintaining compliance with program requirements.

Dos and Don'ts

When filling out the DSHS form, here are four important do's and don'ts to keep in mind:

Do provide your full name, address, and signature, or the signature of your authorized representative to ensure your application is processed correctly.
Don’t leave any required fields blank. Incomplete applications can lead to delays in receiving assistance.
Do submit your review as soon as possible, along with any additional requested information, to possibly receive benefits sooner.
Don’t ignore deadlines. Make sure to apply for assistance within the specified time limits to maintain eligibility.

Following these guidelines can enhance your experience and help you receive the support you need in a timely manner.

Misconceptions

1. Anyone can fill out the DSHS form without knowing the details. Many believe that they can complete the form without understanding the information required. However, it's essential to have accurate details about household income, resources, and household members to avoid delays or denials of assistance.

2. The form can only be submitted by the person applying for assistance. Many think that only the individual needing assistance can submit the form. In reality, an authorized representative can also submit the form on behalf of the applicant, ensuring assistance to those unable to complete it themselves.

3. Submitting an incomplete form will automatically disqualify you. While it's beneficial to provide complete documentation, applicants can initially submit their name, address, and signature to begin the process. Additional information can be provided later to help secure benefits quicker.

4. Submitting the DSHS form guarantees instant assistance. Many assume that submitting the form instantly means they will receive immediate help. However, assistance starts within specific timeframes based on eligibility decisions, which can vary based on the program.

5. All household members need to provide their Social Security Numbers. Not all individuals in the household are required to provide their SSNs. Only those applying for benefits must supply their SSN, while additional household members may only be included for verification purposes.

6. Food benefits can be received even if other assistance applications are denied. There is a misconception that individuals cannot receive food assistance if they have been denied benefits from other programs. In fact, eligibility for food assistance is often assessed independently from other assistance applications.

7. Privacy concerns prevent sharing of information. Some believe that providing information on the form compromises their privacy. The information given is handled under strict confidentiality regulations, ensuring it's only shared among necessary agencies to determine eligibility.

8. You will be charged for assistance received in your lifetime. There is a belief that all assistance will require repayment. While certain medical and long-term care services may require reimbursement from an estate after death, many assistance programs are not subject to repayment.

9. Those with disabilities cannot apply for cash and food assistance. Some individuals think that having a disability disqualifies them from assistance programs. In reality, there are specific provisions in place to support individuals with disabilities, making it important for them to apply.

Key takeaways

Eligibility Review: Keep this page for your records as it includes vital information.
Provide your name, address, and signature or the signature of your authorized representative to begin the application process.
You may increase your chances of receiving benefits sooner by completing and submitting your review quickly.
You can submit your review in person at a local office, by fax, or by mail to specified addresses.
Online submission is also available at www.washingtonconnection.org.
The form is specifically for renewing coverage for the Washington Apple Health programs.
Benefits are usually issued within a day after your eligibility is determined, especially for urgent food assistance.
Be aware that the application for food assistance must be processed within 30 days.
It is essential to provide accurate information, as discrepancies can affect eligibility.
If you experience issues with the form, do not hesitate to ask for assistance.