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Application for Cash or Food Assistance

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How do I apply for cash or food assistance?

Complete the attached application. You can start the process today by submitting the application in-person at a local community services office. The application must have your name, address, and signature or the signature of your authorized representative. If you don’t have an address, contact your local office for resources to acquire a mailing address. Attach more sheets if you need more space.

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.

Take your application to a local office. See www.dshs.wa.gov for locations.

Fax your application to 1-888-***-****

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-***-****, 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. Benefits are issued 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. Civil Rights

In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food and Nutrition Act of 2008 and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs. To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call 202-***-**** (voice and TDD). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call 202-***-**** (voice) or 202-***-**** (TTY). USDA and HHS are equal opportunity providers and employers. DSHS 14-001 (REV. 04/2014) Page 1

Immigration Status and Social Security Numbers

You may be able to get assistance for some people you live with even if others you live with can’t get help because of immigration status. You must tell us the immigration status of anyone who applies. Under Federal Law (45 CFR §205.52, 7 CFR §273.6), you must give us the Social Security Number (SSN) for anyone you live with who applies for TANF, or food assistance. We may also need SSNs of parents and spouses who live with you but don’t apply.

We use SSNs to check identity, verify eligibility, prevent fraud, and collect claims. We exchange information with other agencies to manage our programs and follow the law. We may also give this information to law enforcement agencies trying to catch fleeing felons.

Privacy and Your Cash and Food Assistance

The Food and Nutrition Act of 2008, as amended, permits the department to collect the information we ask for on the application, including the SSN of each household member. Providing the requested information is voluntary. However, failure to provide a SSN or proof of application for a SSN without a good reason will result in the denial of Basic Food assistance to each individual failing to provide a SSN We verify some of this information with computer matching programs, including the federal Income and Eligibility Verification System (IEVS). 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. We use this information to: We may give this information to:

Decide who is eligible for our programs.

Collect overpayments.

Manage our programs.

Make sure we follow the law.

Federal and state agencies for official use.

Law Enforcement agencies pursuing people who are fleeing to avoid the law.

Private collection agencies to collect food assistance overpayments. Food Assistance Penalty Warning

We do send information about persons applying for Food Assistance to other Federal agencies to check that the information is correct. If any information is incorrect, the persons who apply may not get Food Assistance. If a person provides information that they know is incorrect, they could be criminally prosecuted. Penalties for intentionally breaking Food Assistance rules vary from disqualification from the program, to fines, or possibly imprisonment. DSHS 14-001 (REV. 04/2014) Page 2

Application for Food and Cash Assistance

Ask us if you need help filling out this form.

1. FIRST NAME MIDDLE INITIAL LAST NAME

SIGNATURE OF APPLICANT OR

AUTHORIZED REPRESENTATIVE

(REQUIRED)

2. CLIENT IDENTIFICATION NUMBER

(IF KNOWN)

3. STREET ADDRESS WHERE YOU LIVE CITY STATE ZIP CODE 4. HOME/PREFERRED PHONE NUMBER

5. MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE 6. OTHER PHONE NUMBER(S)

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

Cash Food Child care

7. EMAIL ADDRESS

9. I or someone in my household (check all that apply): Are in a domestic violence situation Have a disability Can’t work because of health problems Are pregnant; name: due date: 10. How much money do you expect your household to get this month? $ 11. How much money does your household have in cash and bank accounts? $ 12. How much does your household pay for rent or mortgage? $ 13. What utilities does your household pay for? Heating/cooling Telephone Other: 14. Is anyone in your household a seasonal or migrant farm worker? Yes No 15. If applying for food assistance, how many people in your household do you buy and prepare food for? 16. If applying for child care, what activity do you need care for (check all that apply)? Work School WorkFirst Basic Food Employment and Training (BFET) FOR OFFICE USE ONLY – Household eligible for expedited service: Yes No Screener’s Initials: Date: 17. I need an interpreter. I speak: or sign; translate my letters into: 18. List everyone in your household even if you are not applying for them (attach additional sheets, if necessary). NAME

(FIRST, MIDDLE,

LAST)

SEX

M

OR F

HOW IS THIS

PERSON

RELATED TO

YOU?

DATE OF

BIRTH

CHECK IF

YOU WANT

BENEFITS

FOR THIS

PERSON

OPTIONAL FOR NON-APPLICANTS

SOCIAL

SECURITY

NUMBER

CHECK

IF U.S.

CITIZEN

RACE (SEE

SAMPLES

BELOW)

TRIBE NAME

(For American

Indians, Alaska

Natives)

Myself

19. My ethnic background is Hispanic or Latino: Yes No Race and Ethnic background information is voluntary. For Food Assistance the USDA requires us to answer for you if no information is provided. Race examples: White, Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, or any combination of races. DSHS 14-001 (REV. 04/2014)

Page 3

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

I. General Information

1. In the past 30 days, I received cash or food from another state, tribe, or other source. Yes No 2. Someone I’m applying for lives outside Washington State: Yes No Who: 3. I or someone in my household is a sponsored alien: Yes No Who: 4. I or someone in my household age 16 or older is in (check all that apply): a High School Equivalency Program High School College Trade School Who:

5. I or someone I’m applying for would like information about Employment and Training Services (BFET): Yes No 6. Someone is temporarily out of my home: Yes No Who: 7. I or someone I’m applying for served in the military: Yes No Who: 8. Someone is the dependent or spouse of someone (living or deceased) who served in the military: Yes No 9. 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

10. I am living in: My own house or apartment Group Home Other: Facility (list type): Date entered:

11. I am: Single Married Divorced Separated Widowed In a Registered Domestic Partnership

II. Resources (Attach Proof; Cash 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

Checking accounts

Savings accounts

College funds

Trusts

IRA / 401k

Homes, Land or

Buildings

CDs

Money market account

Bonds

Retirement fund

Burial funds, prepaid plans

Business equipment

Livestock

Life insurance

Please list the resources you, your spouse, or anyone you are applying for owns or is buying: RESOURCE WHO OWNS LOCATION VALUE 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

(E.G., 1980)

MAKE (E.G., FORD) MODEL (E.G., ESCORT) CHECK IF LEASED CHECK IF VEHICLE IS USED

FOR MEDICAL PURPOSES

AMOUNT OWED

$

$

$

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 (Investments made by any household member to receive regular payments now or in the future.) WHO OWNS THE ANNUITY? COMPANY OR INSTITUTION? AMOUNT OR VALUE MONTHLY INCOME DATE PURCHASED

$ $

$ $

$ $

DSHS 14-001 (REV. 04/2014) Page 4

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

IV. Earned Income Attach Proof

1. I, my spouse, or someone I'm applying for had a job that ended in the past 60 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

EMPLOYER’S NAME AND PHONE NUMBER

START DATE

Is this job self-employment? Yes No

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

DEDUCTIONS)

$ every: Hour Week

Two weeks Twice a month Month

Hours per week:

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

WHO EARNS THIS INCOME

EMPLOYER’S NAME AND PHONE NUMBER

START DATE

Is this job self-employment? Yes No

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

DEDUCTIONS)

$ every: Hour Week

Two weeks Twice a month Month

Hours per week:

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

V. Other Income (Attach Proof; Use for all household members)

Unemployment benefits

Social Security income

Tribal income

Gaming income

Educational benefits (student

loans, grants, work - study)

Supplemental Security income

(SSI)

Child Support or spousal

maintenance

Railroad benefits

Rental income

Retirement or pension

Veteran Administration (VA) or

military benefits

Labor and Industries (L&I)

Trusts

Interests / Dividends

UNEARNED INCOME TYPE WHO GETS THE INCOME?

GROSS MONTHLY

AMOUNT

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, my spouse, or someone in my household pay or are supposed to pay (check all that apply): Child or Adult Dependent Care

(including transportation costs)

Monthly amount: $ Who pays:

Medical bills for persons with

disabilities or age 60 +

(including transportation costs and

health insurance premiums)

Monthly amount: $ Who pays:

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. 04/2014) Page 5

VII. Authorized Representative

An Authorized Representative is someone you allow DSHS to talk with about your benefits. You can name someone, but you do not have to. Do you have an Authorized Representative? Yes No Is this person your legal guardian? Yes No

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

RELATIONSHIP

TELEPHONE NUMBER

MAILING ADDRESS CITY STATE ZIP CODE

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. 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. 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 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 14-001 (REV. 04/2014) Page 6

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