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Fill Out Your Dshs Form

The DSHS form, officially known as the Eligibility Review form, is a vital document for those seeking assistance with programs like cash or food benefits in Washington State. Completing this form accurately helps individuals and families renew their coverage effectively, ensuring timely access to necessary resources. If you need assistance with filling out this form, please don’t hesitate to reach out for help.

Ready to apply for assistance? Fill out the DSHS form by clicking the button below.

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The DSHS form is essential for individuals seeking cash or food assistance through Washington State's Department of Social and Health Services (DSHS). This form enables applicants to review their eligibility for various programs, specifically targeting Washington Apple Health. To get started, applicants must provide basic information, including their name, address, and signature, which can even be submitted in an incomplete form to expedite the benefits process. There are multiple submission methods available, such as faxing, mailing, or filling out the form online. It is crucial to act swiftly as certain programs, like food assistance, have time-sensitive eligibility rules. In addition to personal details, the form requires information about household finances, employment, and, if applicable, immigration status or Social Security numbers. Understanding the implications of this form is equally important, as it informs users about their rights, civil protections, and responsibilities under federal and state regulations. For those needing immediate assistance, particular sections of the form can streamline the process, ensuring that help can arrive typically within a week. Compliance with these guidelines helps to ensure that benefits are distributed fairly while protecting the integrity of the assistance programs in place.

Dshs Example

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: program.intake@usda.gov

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

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

Page 1

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)

Page 2

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)

Page 3

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)

Page 4

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)

Page 5

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)

Page 6

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

Get Dshs PDF Form

Form Characteristics

Fact Name	Details
Application Flexibility	Individuals can apply for cash or food assistance by submitting an eligibility review at any community services office. Just include your name, address, and signature, or that of your authorized representative. The process can start with these three items alone.
Eligibility Timeline	For food assistance, eligibility will be determined within 7 days if proof of identity is provided. General eligibility decisions for food assistance must be made within 30 days of application submission.
Civil Rights Compliance	The USDA and other agencies involved are bound by Federal civil rights laws, prohibiting discrimination based on various factors, including race, gender identity, and disability. Complaints can be filed through specific channels.
Repayment Obligations	Under Washington State Estate Recovery laws, individuals may have to repay the state for medical and long-term services after the age of 55. These obligations come into effect after the individual's death or under certain conditions regarding property transfer.

Guidelines on Utilizing Dshs

Completing the DSHS form is an essential step in seeking assistance. Once filled out, the form can be submitted to the appropriate office for processing. This will help ensure timely assistance for you or your household. Below are the specified steps to guide you through filling out the form accurately.

Provide your first name, middle initial, and last name. Ensure accuracy, as this is crucial for identification.
If you have a client ID number, include it. If not, you may skip this step.
Fill in your street address, including the city, state, and zip code where you reside.
List your primary phone number and indicate whether it is a cell or home number. Include a message option if necessary.
If different from your residential address, provide your mailing address, along with the corresponding city, state, and zip code.
Include any secondary phone numbers, specifying if they are cell or home numbers.
Provide your email address if you have one.
In the appropriate section, check all that apply for the assistance you are seeking: cash, food, Medicare Savings Program, etc.
Indicate if you or someone in your household faces any special circumstances such as domestic violence, health problems, or pregnancy.
State the expected household income for the upcoming month.
Declare the total amount of cash and bank accounts your household currently holds.
List your total rent or mortgage payment.
Identify which utilities you pay, such as heating, cooling, or telephone.
Answer whether anyone in your household is a seasonal or migrant farm worker.
If applying for food assistance, mention how many individuals you buy and prepare food for.
If you need an interpreter, specify your language or sign language needs.
List all members of your household, including necessary details like name, gender, date of birth, and Social Security Number, even for non-applicants.
Complete any additional questions as directed regarding your situation, financial resources, and health coverage.
Finally, review your completed form for accuracy and ensure every part has been filled out before submitting.

Once you have completed the form, you can submit it to a local DSHS office, fax it, mail it, or complete it online, depending on your preference and instructions provided. It is advisable to keep a copy for your records.

What You Should Know About This Form

What is the purpose of the DSHS form?

The DSHS (Department of Social and Health Services) form serves as an eligibility review tool for individuals seeking cash or food assistance. By filling out this form, applicants provide essential information that helps determine their eligibility for programs such as the Washington Apple Health. The submitted form must include the applicant's name, address, and signature, or that of an authorized representative, to initiate the review process.

How can I apply for food or cash assistance using the DSHS form?

You can begin your application by submitting the DSHS form at a community services office. It’s essential to include your name, address, and signature, as these are required elements for the submission. If you're able to provide additional information right away, this may expedite your access to benefits. You have the option to deliver your review in person, via fax to 1-888-338-7410, or by mail to designated addresses listed on the form. Alternatively, the review can be filled out online at www.washingtonconnection.org, making the process more accessible.

How quickly can I expect to receive assistance after applying?

If you apply for food assistance and demonstrate proof of identity, eligibility decisions can be made within 7 days. Generally, food assistance benefits begin once your application is received. For cash assistance, the start date is contingent upon gathering all necessary information for eligibility determination. The entire evaluation process should be completed within 30 days for food assistance applications, with expedited services available for those who qualify.

What information is required when filling out the DSHS form?

Completing the DSHS form requires various personal details. You’ll need to provide information such as your address, household composition, income details, and potential resources. Not only do you need to disclose your expected income and expenses, but you may also be asked to submit documents that verify these financial details. Additionally, you must answer questions regarding your immigration status and citizenship, which are vital for assessing eligibility for assistance programs.

Common mistakes

Filling out the DSHS form can be a daunting task, and many people encounter pitfalls along the way. Here are seven common mistakes to avoid for a smoother application process.

First, incomplete information is often a major issue. Applicants frequently neglect to provide a signature or fill in all necessary fields. This can delay the review process significantly. It is crucial to ensure that your name, address, and contact information are all filled out clearly. Take the time to double-check that every required section is completed prior to submission.

Second, neglecting to include relevant supporting documents can hinder your application. The DSHS form sometimes requires proof of identity, income, or residency. Omitting these documents can lead to requests for additional information or even outright denial. It's wise to gather all relevant documents beforehand to streamline the process.

Another frequent misstep is failing to list all household members. Some applicants may mistakenly think they only need to include individuals who will be applying for benefits. In reality, all household members typically need to be disclosed, even if they are not applying themselves. This omission can impact eligibility determinations.

Fourth, many individuals overlook the importance of accuracy in reporting financial information. This includes details about income, bank accounts, and expenses. Inaccuracies can lead to delays or, worse, consequences regarding eligibility for assistance. Always ensure that the figures you provide are correct and sourced from reliable documents.

Additionally, waiting too long to submit the form can result in missed opportunities for assistance. The sooner the form is completed and submitted, the better. Some benefits can be approved quickly if the application is thorough and correct. Promptness can play a significant role in how soon benefits are received.

Another common error involves not understanding eligibility requirements. Some applicants may apply for programs they are not qualified for, which could frustrate their efforts. It's advisable to carefully read through the eligibility criteria stipulated in the application before submitting it to ensure you meet the necessary guidelines.

Lastly, failing to seek help when needed can lead to complications. Many people shy away from asking for assistance due to embarrassment or uncertainty. However, DSHS encourages applicants to ask for help with completing the form if they're unsure about certain aspects. Utilizing available resources can simplify the process and minimize mistakes.

Documents used along the form

The DSHS form is an important tool for accessing various assistance programs. When applying for these benefits, several other documents and forms might be required. Each serves a specific purpose in the review process.

HCA Application for Health Care Coverage (HCA 18-001): This form is necessary for individuals seeking health care coverage other than what’s provided by the DSHS form. It helps determine eligibility based on different criteria.
USDA Program Discrimination Complaint Form (AD-3027): This form allows individuals to report discrimination related to USDA programs. It ensures that all applicants receive equal treatment under the law.
Proof of Identity Documents: Applicants may need to provide identity verification, such as a driver’s license or passport. This is crucial for establishing eligibility for assistance.
Proof of Income Documents: Applicants are often required to submit recent pay stubs, tax returns, or bank statements. These documents are used to assess financial eligibility.
Resource Verification Form: This form collects detailed information about any financial assets the individual or household may have. It includes items like savings accounts and property ownership.
Authorization to Release Information Form: If an authorized representative is assisting with the application, this form is required to allow for the sharing of personal information with that third party.
Nutritional Assessment Survey: This document may be requested to evaluate the nutritional needs of applicants, particularly for food assistance programs.
Language Assistance Request Form: Applicants who need language support can use this form to request translation services or assistance in their preferred language during the application process.

Filling out these documents accurately and providing all required information will help streamline the application process. Always remember to keep copies for your records, and don't hesitate to ask for assistance if needed.

Similar forms

Food Assistance Application: Similar to the DSHS form, this application allows individuals to request access to food assistance benefits. It requires personal information, income details, and proof of residency, similar to the eligibility review process outlined in the DSHS form.
TANF Application: The Temporary Assistance for Needy Families (TANF) application is akin to the DSHS form. Both serve to assess eligibility for financial support, gathering necessary information regarding household composition, income, and needs.
Medicaid Application: Just like the DSHS form, applying for Medicaid requires disclosing personal and financial information to determine coverage eligibility. Both forms aim to streamline access to essential health services.
Supplemental Security Income (SSI) Application: The SSI application is similar in purpose to the DSHS form. It requires documentation and details regarding income and resources to evaluate eligibility for financial assistance for disabled or elderly individuals.
Healthcare Coverage Application (HCA 18-001): This application, which is used for healthcare coverage, also demands detailed personal and financial information. It strives to ensure that applicants can receive appropriate health benefits, parallel to the process described in the DSHS form.
Unemployment Benefits Application: The Unemployment benefits application assesses eligibility based on previous employment, earnings, and present employment status. Like the DSHS form, it requires honesty and transparency, providing necessary information to help applicants receive timely assistance.
State Housing Assistance Application: This application seeks to determine eligibility for various housing benefits. Much like the DSHS form, it collects detailed household information and assesses financial needs to provide necessary housing assistance.

Dos and Don'ts

When filling out the DSHS form, there are several important considerations to keep in mind. Here’s a list of things you should and shouldn't do to ensure your application proceeds smoothly.

Do ensure that you provide your name, address, and signature, either your own or that of your authorized representative.
Don't submit incomplete forms if you want to receive benefits sooner. Fill out as much information as possible.
Do take your completed form to a local office if you need immediate food assistance, specifically questions 1 through 14.
Don't forget to keep a copy of the form for your records, as this is important for future reference.
Do check all information for accuracy before submission. Errors can lead to delays or denials.
Don't omit any required information, such as Social Security Numbers for everyone applying for assistance.
Do provide proof of identity if necessary, especially if applying for food assistance.
Don't assume that your application will be processed without submission of required documentation.
Do contact DSHS if you need assistance understanding or completing the form.

Misconceptions

Misconception 1: The DSHS form can be submitted without any information.

This is not accurate. Individuals must provide at least their name, address, and signature, or the signature of an authorized representative. Submitting only these minimal items allows for the initiation of the process, but additional information may be required to fully complete the review.

Misconception 2: Food assistance benefits will always start immediately after application.

Food assistance benefits generally commence the day the application is received, with the exception of expedited services, which can start sooner if specific criteria are met. However, it may take longer for cash assistance to begin, as it relies on the collection of all required information.

Misconception 3: Immigration status affects eligibility for all household members.

Eligibility may vary based on individuals' immigration status within a household. Some members of the household might qualify for assistance even if others do not, depending on their specific circumstances. It is crucial to accurately report the immigration status of all applicants.

Misconception 4: Providing a Social Security Number (SSN) is optional for all applicants.

Providing an SSN is mandatory for those applying for Washington Apple Health, TANF, or food assistance. Failure to disclose SSNs may directly impact eligibility and benefit amounts for these programs.

Key takeaways

When filling out and using the DSHS form, consider these key takeaways:

Ensure your review contains your name, address, and signature, or the signature of an authorized representative.
Submitting your review early can lead to receiving benefits more quickly or potentially increasing the amount of assistance.
You can submit your review at a local office, fax it to 1-888-338-7410, or mail it to designated DSHS addresses.
Online submission is available through www.washingtonconnection.org.
Receive food assistance within 7 days by completing specific questions and providing proof of identity.
Eligibility decisions for food assistance must occur within 30 days following your application submission date.
If you encounter issues or need clarification, don’t hesitate to ask DSHS for assistance.
Be aware that some individuals may be eligible for assistance despite differing immigration statuses within your household.
Reporting accurate information is vital. Providing false details could lead to severe penalties, including disqualification from benefits.

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