Forms you might need

These forms are available at your local Community Service Office. Some of these forms can be filled out on-line and then printed out. Some of the forms are in the Adobe Acrobat (PDF) format. You will need the free Adobe Acrobat Reader to open them. If you do not already have this program, you may click on the icon below to install it.

Interactive Forms that can be filled out and submitted on-line

Application for Benefits (form 14-001)

This link will take you to the start page for the Online Application. To start your application, click on the APPLY NOW tab at the top of the page.

Application for Children's Medical Benefits

This link will take you to the Washington Healthplanfinder site where you may submit your application online. This application is only for individuals under the age of 19 who want medical benefits.

Child Care Subsidy Program Application (form 14-417)

This link will take you to the application form for Child Care Subsidy Program.  You may call the Child Care Subsidy Contact Center at 1-844-626-8687 to request a form.  Mail the complete application form to DCYF, PO Box 11346, Tacoma, WA 98411-9903, or fax to 877-309-9747.  You may also submit an online application through www.washingtonconnection.org.   

Application for Benefits  | Interactive Forms ( complete on-line and then print)  |  Pamphlets  |  Printable Forms

 

  • Application for Benefits (form 14-001) - This form is completed to request benefits. PDF format. Translations.

The Application for Benefits is available in several languages. 

English - Application for Benefits form [English]

Cambodian - Application for Benefits form [Cambodian]

Chinese - Application for Benefits form [Chinese]

Korean - Application for Benefits form [Korean]

Laotian - Application for Benefits form [Laotian]

Russian - Application for Benefits form [Russian]

Somali - Application for Benefits form [Somali]

Spanish - Application for Benefits form [Spanish]

Vietnamese - Application for Benefits form [Vietnamese]

Get Adobe Adobe Acrobat Reader

  • Authorization for Alternate EBT Cardholder (form 27-130)

This form is used when you, the Head of Household (HOH), wants to authorize someone you trust to help use your food or cash benefits.  You and the person selected need to complete and sign the form and take it to your nearest Community Services Office to get the alternate EBT card.

Microsoft Word Format.  Translations.

  • Authorization to Release Information (form 17-063)

This form is used when someone needs to authorize another to obtain their records.
Microsoft Word format. PDF format.

  • Background Authorization - ESA (form 09-653.) [formerly form 09-891]

This form is used to request criminal background inquiry to determine eligibility for: WCCC, TANF (in loco parentis), Protective Payee, & Contractor.
Microsoft Word format. PDF format.Translations.

  • Child Support Enforcement Referral (form 14-057)

This form is to provide information on the Absent Parent.
PDF format. Translations.

  • Client's Rights and Responsibilities (form 14-113)

This form is completed at each Eligibility Review.
PDF format. Translations.

  • Consent to Exchange Confidential Information for Services Coordination (form 14-012)

This form is used when a person needs to authorize the sharing of his or her information between programs, either inside or outside of the agency, to coordinate services.
Microsoft Word format. PDF format. Translations.

  • Eligibility Review (form 14-078)

Eligibility Review forms can also be used to apply for benefits.
PDF format. Translations.

  • Fair Hearing Withdrawal (form 02-528)

This form is used when your Fair Hearing issues is resolved prior to the hearing date.
Microsoft Word format. PDF format.

  • Mid certification review (form 14-467)

  • Personal Pathway (form 11-154)

    This form is a brief self-assessment that helps you choose what you want to focus on most and it can show you options that may be available to you and your family. The Personal Pathway is available in several languages. 

English | Foreign language | 个人路径 | 개인 경로 | Foreign language 2 | Личный маршрут | Dhabooyinka Gaarka ah | Ruta personal | Lộ Trình Cá Nhân 

  • Request for Fair Hearing (form 05-013)

If you do not agree with an action that has been taken in reducing, terminating or denying benefits, you may request a hearing to review the action. This form can be completed and returned to the address on the form or your local Community Service Office.
Microsoft Word format. PDF format. Translations.

  • Single Parent Declaration (form 27-164)

This form is used when you apply for benefits as a single parent and need to provide information about the other parent of any of your children.

Microsoft Word format.   Translations

  • Employment Verification (form 14-252)

This form is used when you start work or self employment.  (This form used to be called the "Start Work" form.)
PDF format. Translations.

  • Stop Work Questionnaire (form 14-438)

This form is used when you stop work or self employment. The form should be signed by you but must be completed by your employer. Your employer can also complete this form On-Line.
PDF format. Translations.

  • Statement of Collateral Information (form 14-222)

This form is completed by the person providing the information that your case worker has requested. You would complete Section 2, print it out and sign it. The person providing your collateral information would complete Section 3.
Microsoft Word format. PDF format. Translations.

  • Statement of Education, Employment and Health (form 14-050)

This form is completed by you. This forms helps us learn more about your health problems and possible sources of medical evidence. It also gives us a history of your education and work experience.
Microsoft Word format. PDF format. Translations.

  • Statement from Landlord/Manager(form 14-224)

This form is used to verify where you live, who lives with you, how much your rent is and what utilities you are responsible for. The landlord/manager completes all portions of this form. Your landlord can complete this form On-line.
Microsoft Word format. PDF format. Translations.

  • Statement from School (form 14-223)

This form is used to verify that you or your children are in school and the expected date of graduation. You would need to complete Section 2, print it out and sign it. The school completes Section 3.
Microsoft Word format. PDF format. Translations.

  • Your Options for Child Support Collection while Receiving Temporary Assistance For Needy Families (TANF) (Form 18-334)​​

​This form is to be completed by all TANF households when there is a non-custodial parent of one of the children on TANF.  This form allows parents/caregivers to report safety concerns and their sworn statement can be used as good cause verification to not follow through with the collection of child support.
Microsoft Word Format. PDF format. Translations 

 

Pamphlets

  • How to Use Your Washington EBT Quest Card (form 22-310)

Recipients of food assistance are issued an Electronic Benefits Transfer (EBT) Card. This card, also called a "Quest Card", is used like a debit card to purchase food items at stores. This online pamphlet tells how and where to use the card once approved for benefits.
PDF format. Translations.

Printable Forms

  • Change of Circumstances (form 14-076)

Form for reporting changes or requesting termination. This form also lists what changes need to be reported.
PDF format. Translations.