Application for Cash or Food Assistance

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 application in-person at a community services office. The

application must have your name, address, and signature or the signature of your authorized representative.

You can file your application immediately even if it only contains these three items.

• You may get more benefits or get them sooner if you complete the form by answering the questions, signing

page six and giving us your application and any other information we ask for as soon as you can.

• You can take your application to a local office. See www.dshs.wa.gov

for locations.

• Fax your application to 1-888-338-7410

• Mail your application to the following: DSHS

CSD-Customer Service Center

PO Box 11699

Tacoma, WA 98411-6699

• You can also apply online at www.washingtonconnection.org

• For health care coverage you must apply either online at www.wahealthplanfinder.org, by calling

1-855-923-4633, or by using the HCA Application for Health Care Coverage (HCA 18-001).

How soon can I receive help with food and cash assistance?

If you need food assistance right away, fill in Questions 1 through 14 and take this form to your local office.

We decide if you are eligible for food assistance within 7 days if you show proof of your identity and meet one of

the following:

• Your household will have less than $150 gross income and less than $100 liquid resources this month.

• Your household’s income and resources are less than your monthly rent and utilities.

• Your household includes a destitute migrant or seasonal farm worker.

Benefits are issued by the day after we decide you are eligible. We must decide if you are eligible for Food

Assistance within 30 days of the date you submit your application. Food assistance usually starts the day we

receive your application. If you are submitting your application from an institution, the start date is the date of

your release or discharge. Cash assistance usually starts the day we have all the information to decide you are

eligible.

Civil Rights and Nondiscrimination

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and

policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including

gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation

for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who

require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape,

American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals

who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service

at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program

Discrimination Complaint Form which can be obtained online at:

https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (833) 620-

1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address,

telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the

Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation.

The completed AD-3027 form or letter must be submitted to:

1. mail: Food and Nutrition Service, USDA

1320 Braddock Place, Room 334

Alexandria, VA 22314; or

2. fax: (833) 256-1665 or (202) 690-7442; or

3. email: [email protected]ov

This institution is an equal opportunity provider.

DSHS 14-001 (X) (REV. 03/2024) 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. Alien status of

applicant household members may be subject to verification by USCIS (formerly known as INS) through the

submission of information from the application to USCIS. Information received from USCIS, based on this

submission, may affect eligibility and benefit amounts.

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.

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.

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. 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. 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 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 f

ood

sistance overpayments.

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 14-001 (X) (REV. 03/2024) Page 2

Application for Food and Cash Assistance

Ask us if you need help filling out this form.

If you’re unable to complete this form today, start the process by submitting your name, address, and

signature. You will still need to complete the application before benefits can be approved.

A signature on page six is required to complete your application.

1. FIRST NAME MIDDLE INITIAL LAST NAME

SIGNATURE OF APPLICANT OR

AUTHORIZED REPRESENTATIVE

2. CLIENT IDENTIFICATION NUMBER

(IF KNOWN)

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 Food Child care

9.I or someone in my household (check all that apply):

7. EMAIL ADDRESS

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 needed).

NAME

(F IRS T,

MIDDLE,

LAST)

GENDER

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 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. We will select

“unreported” if you don’t want to answer. Race examples: White, Black or African American, Asian, Native

Hawaiian, Pacific Islander, American Indian, Alaska Native, or any combination of races.

DSHS 14-001

(X) (REV. 03/2024)

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): 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

depe

ndent 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

II. Resources (Attach Proof; For Cash Assistance Only)

A resource is anything you own or are buying that can be sold, traded, or converted into cash or money held by

others. A resource does not include personal property such as furniture, or clothing. Examples of resources are:

• Cash

• 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

1. 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

(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 (X) (REV. 03/2024)

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 30 days: Yes No

2. I, my spouse, or someone I'm applying for has income from work: Yes No

If yes, please complete this section:

WHO EARNS THIS INCOME

EMPLOYER’S NAME AND PHONE NUMBER

START DATE

Is this job self-employment? Yes No

Monthly self-employment expense amount: $

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

DEDUCTIONS)

$ every: Hour Week

Two weeks Twice a month Month

Hours per week:

Pay dates (e.g., 1

and 15

, or every Friday):

WHO EARNS THIS INCOME

EMPLOYER’S NAME AND PHONE NUMBER

START DATE

Is this job self-employment? Yes No

Monthly self-employment expense amount: $

GROSS AMOUNT RECEIVED (DOLLAR AMOUNT BEFORE

DEDUCTIONS)

$ every: Hour Week

Two weeks Twice a month Month

Hours per week:

Pay dates (e.g., 1

and 15

, or every Friday):

V. Other Income (Attach Proof; Report 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

VI. Monthly Expenses

RENT

MORTGAGE

SPACE RENT

HOMEOWNER’S INSURANCE

PROPERTY TAXES

OTHER FEES

What utilities does your household pay for separately from rent or mortgage?

Heat (Electric/Gas) Electric (Not Heat) Water Home/Cell Phone Sewer Garbage

Another person or agency, such as subsidized housing, helps me pay either all or part of these expenses:

Yes No If yes, who: What expense: Amount they pay: $

I received a Low Income Home Energy Assistance Act (LIHEAA) payment in the past 12 months.

I, my spouse, or someone in my household pay or are supposed to pay (check all that apply):

Child or Adult Dependent Care

(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 (X) (REV. 03/2024)

Page 5

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

CLIENT IDENTIFICATION NUMBER

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

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 No

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 No

If you checked the box marked “Yes,” or do not check either box and you meet automatic voter

registration eligibility requirements, DSHS will send your information to the Office of the Secretary of

State and you will be automatically registered to vote.

Declaration and Signatures (Sign below to complete your application.)

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 Assistanc

or 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.

If applying for cash assistance, all adults (or authorized representatives) in the household must sign.

For food assistance, both the applicant and authorized representative must sign unless there is a

current authorized representative document on file.

APPLICANT’S SIGNATURE (REQUIRED) DATE PRINTED NAME OF APPLICANT CITY AND STATE SIGNED

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

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

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

DSHS 14-001 (X) (REV. 03/2024)

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