IDesILaytagsJ~1DSHS ASDState of Washington 1444607200314_44672003C]O 0/6"4jF  e_DEEFpW J~ZJ &,28>DJPV\bhntz6fSubmit 6 Vj@yk qg6h@6$64*50469041744506000jH"-- ###-##-#### // () -(###) ###-####(000) 000-0000r###000#,##0.00@@X  SV @@@@@@ @@@@@?HH >?8 =>HH =>8 <=HH <=8 ;<HH ;<8 :;HH :;8 9:HH 9:8 89HH 898 78HH 788 67HH 678 56HH 568 45HH 458 34HH 348 23HH 238 12HH 12H 01HH 01H /0HH /0H ./HH ./H -.HH -.H ,-HH ,-H +,HH +,H *+HH *+H )*HH )*H ()HH ()H '(HH '(H &'HH &'H %&HH %&H $%HH $%H #$HH #$H "#HH "#H !"HH !"H !HH  !H  HH  H HH H HH H HH < HH < HH < HH < HH < HH < HH < HH < HH < HH < HH < HH 2 HH 2 HH 2 HH 2 HH  2 HH  2 HH  & HH  & HH  &  HH  & HH & HH & HH & HH & HH & HH & HH & HH  .`/@ 5DECLARATION OF FINANCIAL STATUS DSHS 00-000 (00/2003)   ,Arial (& DECLARATION OF FINANCIAL STATUS (&DSHS 00-000 (00/2003)@@$` @  RESOURCES  ' ? \dlt|s`    tg  $un,4<DLT\dl tvu!|"#$%&'()*ew|+,-./0123 4x36Cell237Cell258Cell259Cell241Cell242Cell243Cell244Cell260Cell261Cell248Cell249Cell250CZJl263Cell264Cell265Cell266Cell267Cell268Cell270Cell271Cell272Cell273Cell274Cell276ZJell279Cell280Cell282Cell283Cell284Cell285Cell286Cell288Cell289Cell290Cell291Cell292Cell294Cell295Cell296Cell297Cell298@@X   @@@   @@X   25=HNTZN"T[@@@@@DB@P CHILDREN'S ADMINISTRATION     P DECLARATION OF FINANCIAL STATUS      ,FOR CHILD PLACED INTO PRIVATE AGENCY CUSTODY    @p$ 8p ;SECTION I - TO BE COMPLETED BY PRIVATE AGENCY SOCIAL WORKER   _ 0@@  d@P 1. PRIVATE AGENCY NAME: *np@0p0$ PP PRIVATE AGENCY    Q @ 0@`  ePa (2. PRIVATE AGENCY SOCIAL WORKER'S NAME: * 0@ @   f @P  03. PRIVATE AGENCY SOCIAL WORKER'S PHONE NUMBER: *0$ @  g@$ 4. CHILD'S BIRTH NAME: *`P CHILD     0 $ @   h @ $ 8. CHILD'S PERSON ID#: *_ 0@`  ia /5. CHILD'S PRESUMPTIVE ADOPTIVE NAME if known: * 0$ @`  ja$ 6. CHILD'S BIRTH DATE: *_ 0 @   k @  #7. CHILD'S SOCIAL SECURITY NUMBER: * @ p$  0  ELIGIBILITY MONTH   X  p@ $   ` NOTE:      #@ The Eligibility Month is the month in which the court action that resulted in the removal of the child from the parent(s) was initiated. This would be the month in which the petition for removal of the child from the biological parent(s)' care was filed.  F> F> a F>,Arial (PpThe Eligibility Month is the month in which the court action that resulted in the removal of the child from the (Pjparent(s) was initiated. This would be the month in which the petition for removal of the child from the (P%biological parent(s)' care was filed. @P@ C  l P 19. ELIGIBILITY MONTH FOR THIS CASE IS: (MM/YYYY) * P$ C @# pThe remainder of this form is to be completed regarding the parent(s) circumstances in this Month and Year only.  %G %G a %G,Arial (/8The remainder of this form is to be completed regarding (/8the parent(s) circumstances in this Month and Year only.P@P$ @   m`$ REMOVAL DATE: (MM/DD/YYYY) *|P [10. When did the child last live under the care and responsibility of one or both parents?    @$ 8p -SECTION II - TO BE COMPLETED BY THE PARENT(S)    @ @ @  nPA 1. MOTHER'S FULL NAME: *f@ @  oP 2. I AM THE BIRTH MOTHER OF: *}@ @0  pP1 '3. THE CHILD WAS BORN ON: (MM/DD/YYYY) *@0  ` @ 4. THE CHILD'S BIRTHPLACE WAS: @ @P  qPQ CITY: *  @P  r Q STATE: *  @P  s Q COUNTRY: **@ 0@`@  t@ P SINGLE *  @  u0 MARRIED *%   p@ v0  ` DIVORCED ** @  w0   SEPARATED *1 0@` x0p WIDOWED *)0@ @  y@P 5. FATHER'S FULL NAME: *d@ @@ z  SINGLE * @ { MARRIED *%  p@ |  ` DIVORCED ** @  }   SEPARATED *10@` ~p WIDOWED *) $  p$@@  0P# 06. We are currently living together, beginning:  * p`  Month/Year )Hp Title  pp$@@  P# ?7. We do not currently live together, but lived together from:  N;yI ;NIy a N;yI,Arial (aF:7. We do not currently live together, but lived together (mFfrom:0pHp Title  `  @ ,    `  @ ,    0` to    0#pH p Title  p@!@  P !>8. We have never lived together.       Month/Year )0!  Month/Year )@`$ 0p PERSONS LIVING IN THE HOME    `@@$ p# >9. Complete the following information for all adults (age 18 and over) living at your address in the Eligibility Month. The Eligibility Month is:  6  G  @ (from Section I, #9).   X ` H"p Title  .@/ 5DECLARATION OF FINANCIAL STATUS DSHS 14-446 (07/2003)  a ,Arial ($ DECLARATION OF FINANCIAL STATUS ($DSHS 14-446 (07/2003)@@$ P!# QUALIFIED ALIEN YES NOI I  I,Arial ( QUALIFIED (!ALIEN ( YES NO!` U.S. CITIZEN YES NO    I  ,Arial ( U.S. CITIZEN ( YES NOp` -RELATIONSHIP TO ME (son, mother, friend, etc)    ,Arial (RELATIONSHIP TO ME ((son, mother, friend, etc)pP  BIRTH DATEG G  G,Arial (`BIRTH (aDATEP SOCIAL SECURITY NUMBER_`@ NAME@%$ @#!0 Title  @%@$"P  Title  %@%"P  Title  %@&"P  Title  %@'"P  Title  %@("P  Title  %@)"P  Title  %!`@#"P   Title    G ,Arial (Tit(le!`%"@#"P   !Title  & &  &,Arial ( Titl(e"%$ @#"P  !"Title  5 5 & 5,Arial (Titl(!e `P a.    PPPPP~P@@ `! P b.    ! !P c.    !"P d.    "#`P e.    #`$ 0 f.    $ $P g.    $%P h.    %@'`$ %p' # >10. Complete the following information for all children (age 17 and under) living at your address in the Eligibility Month. The Eligibility Month is:  9  K  &p`'00 (from Section I, #9).   X &0 'P H$p Title   PP P MM/YYYY' 'p MM/YYYY@`!!HhP!^!bP!`!`'`@($ 'p!(# QUALIFIED ALIEN YES NOmI mI a mI,Arial (| QUALIFIED (!ALIEN ( YES NO'(!` U.S. CITIZEN YES NOr  r  mI r ,Arial ( U.S. CITIZEN ( YES NO'(` -RELATIONSHIP TO ME (son, mother, friend, etc)q q r  q,Arial (RELATIONSHIP TO ME ((son, mother, friend, etc)'(P  BIRTH DATEqG Gq q qG,Arial (`BIRTH (aDATE((p SOCIAL SECURITY NUMBER_'`(` NAME(@.$ @%!0 Title  Q(@.@$"P  Title  (.@%"P  Title  (.@&"P  Title  (.@'"P  Title  (.@("P  Title  (.@)"P  Title  (.!`@#"P   Title    qG ,Arial (Tit(le(!`."@#"P   !Title  & &  &,Arial ( Titl(e(".$ @#"P  !"Title  5 5 & 5,Arial (Titl(!e()P a.    'p('p('p('p('p~('p('`('`()*@P b.    *@+P c.    ++P d.    +,P e.    ,-@0 f.    -@.P g.    ..P h.    'p!^(!b'p!`(!`'p('p('p('p~('p('`('`()*@P b.    *@+P c.    ++P d.    +,P e.    ,-@0 f.    -@.P g.    ..P h.    'p!^(!b'p!`(!` !" "#@6" !#"# NO  "p@#0$ @7!0 Title  "p@#0@8"P  Title  "p#0 @9"P  Title  "p #00@:"P  Title  "p0#0@;"P  Title  "p#0@<"P  Title  "p#0@="P  Title  "p#0$ @>"P  Title  "p#@@ e.  T "p#@@8 "#@ YES "p#@@9 "#@ NO  " #P" @:  " #P" YES "" #P#@;" "##P# NO  #0@#$ @<!0 Title  #0@#@="P  Title  #0# @>"P  Title  #0 #0@?"P  Title  #00#@@"P  Title  #0#@A"P  Title  #0#@B"P  Title  #0#$ @C"P  Title  #@p$ f.  T #0$@= #@$ YES #0$@> #@$ NO  #@ $" @?  #P $" YES #@" $#@@" #P#$# NO  #@$$ @A!0 Title  #@$@B"P  Title  #$ @C"P  Title  # $0@D"P  Title  #0$@E"P  Title  #$@F"P  Title  #$@G"P  Title  #$$ @H"P  Title  $p$@ g.  T #$@B $$ YES #$@C $$ NO  $ $" @D  $ $" YES $" $#@E" $#$# NO  $@%p$ @F!0 Title  $@%p@G"P  Title  $%p @H"P  Title  $ %p0@I"P  Title  $0%p@J"P  Title  $%p@K"P  Title  $%p@L"P  Title  $%p$ @M"P  Title  $p%@ h.  T $%@G $% YES $%@H $% NO  $ %" @I  $ %" YES $" %#@J" $#%# NO  %p@'`$ %p'# >10. Complete the following information for all children (age 17 and under) living at your address in the Eligibility Month. The Eligibility Month is:  9  K  &``' 0 (from Section I, #9).   ] & &P HKp Title  '`@(p$ '(p# QUALIFIED ALIENoG oG  oG,Arial (~ QUALIFIED (ALIEN'(p  U.S. CITIZENo o oG o,Arial (~U.S. (CITIZEN'(p -RELATIONSHIP TO ME (son, mother, friend, etc)oW Wo o oW,Arial (~hRELATIONSHIP TO ME (h(son, mother, friend, etc)'`(p  BIRTH DATEod od oW od,Arial (~5BIRTH (6DATE' (@ SOCIAL SECURITY NUMBER_'p(@ NAME(p@)0$ @L!0 Title   (p@)0@M"P  Title  (p)0 @N"P  Title  (p )00@O"P  Title  (p0)0@P"P  Title  (p)0@Q"P  Title  (p)0@R"P  Title  (p)0$ @S"P  Title  (p)@@ a.   (p)@@M ()@ YES (p)@@N ()@ NO  (p )@" @O  ( )@" YES (p" )@#@P" (#)@# NO  'p ( 'p ( 'p.(2'p0(0'p('p('p('p('p('p()0@)$ @Q!0 Title   )0@)@R"P  Title  )0) @S"P  Title  )0 )0@T"P  Title  )00)@U"P  Title  )0)@V"P  Title  )0)@W"P  Title  )0)$ @X"P  Title  )@p*@ b.   ) )@R )0) YES ) )@S )0) NO  ) )" @T  )0 )" YES ) " )#@U" )0#)# NO  )@*$ @V!0 Title   )@*@W"P  Title  )* @X"P  Title  ) *0@Y"P  Title  )0*@Z"P  Title  )*@["P  Title  )*@\"P  Title  )*$ @]"P  Title  *p*@ c.   )*@W )* YES )*@X )* NO  ) *" @Y  ) *" YES )" *#@Z" )#*# NO  *@+p$ @[!0 Title   *@+p@\"P  Title  *+p @]"P  Title  * +p0@^"P  Title  *0+p@_"P  Title  *+p@`"P  Title  *+p@a"P  Title  *+p$ @b"P  Title  *p+@ d.    *+p@\ *+p YES *+p@] *+p NO  * +p" @^   * +p" YES *" +p#@_"  *#+p# NO  +p@,0$ @`!0 Title   +p@,0@a"P   Title  +p,0 @b"P   Title  +p ,00@c"P   Title  +p0,0@d"P  Title  +p,0@e"P  Title  +p,0@f"P  Title  +p,0$ @g"P  Title  +p,@@ e.    +`,0@a +p,0 YES +`,0@b +p,0 NO  +` ,0" @c  +p ,0" YES +`" ,0#@d" +p#,0# NO  ,0@,$ @e!0 Title  ,0@,@f"P  Title  ,0, @g"P  Title  ,0 ,0@h"P  Title  ,00,@i"P  Title  ,0,@j"P  Title  ,0,@k"P  Title  ,0,$ @l"P  Title  ,@p- f.   , ,@f ,0, YES , ,@g ,0, NO  , ," @h  ,0 ," YES , " ,#@i"  ,0#,# NO  ,@-$ @j!0 Title  ,@-@k"P  !Title  ,- @l"P  "Title  , -0@m"P  #Title  ,0-@n"P  $Title  ,-@o"P  %Title  ,-@p"P  &Title  ,-$ @q"P  'Title  -p-@ g.   ,-@k (,- YES ,-@l ),- NO  , -" @m  *, -" YES ," -#@n" +,#-# NO  -@.p$ @o!0 Title  -@.p@p"P  ,Title  -.p @q"P  -Title  - .p0@r"P  .Title  -0.p@s"P  /Title  -.p@t"P  0Title  -.p@u"P  1Title  -.p$ @v"P  2Title  -p.@ h.   -.p@p 3-.p YES -.p@q 4-.p NO  - .p" @r  5- .p" YES -" .p#@s" 6-#.p# NO   Pp MM/YYYY' 'p MM/YYYY@`!!Hh0$ PDp DOk as is   ( & PpDp$ DOk with correction   ( X PDp! DAnother proof required   ( m ~ pD p00 DApproving Signature ( O~ $D $ 0"@ DDate ( ~ D "  7z!Df08j8j8j8j8j8j@xD8j8j8j8j8j8j8j8j8jCData:6543,-./012+*)(!"#$%&'       ~}|{zyxwvutsrqponmlkjihgfed      |}~zuvwxypqrstklmnofghijabcde\]^_`VWXYZ[PQRSTUJKLMNODEFGHI>?@ABC89:;<=7}~|{vwxyz=<789:;6501234/.)*+,-('"#$%&! porpsila` porpsilaf<E porpsilar porpsilax& l& l& l& l& l& lArialTimes New Roman09Cell210Cell211Cell212Cell213Cell214Cell215Cell216Cell252Cell253Cell220Cell221Cell222Cell223Cell254Cell255Cell227Cell228Cell229Cell230Cell256Cell2576Well236Cell237Cell258Cell259Cell241Cell242Cell243Cell244Cell260Cell261Cell248Cell249Cell250Cell251Cell262Cell263Cell264Cell265Cell266Cell267Cell268Cell270Cell271Cell272Cell273Cell274Cell276Cell277Cell278Cell279Cell280Cell282Cell283Cell284Cell285Cell286Cell288Cell289Cell290Cell291Cell292Cell294Cell295Cell296Cell297Cell298Cell299Cell301Cell302Cell303Cell304Cell305Cell306Cell307Cell308Cell309Cell310Cell311Cell312Cell313Cell314Cell315Cell316Cell317Cell318Cell319Cell320Cell321Cell322Cell323Cell324Cell325Cell326Cell327Cell328Cell329Cell330Cell331Cell332Cell333Cell334Cell335Cell336Cell337Cell338Cell339Cell340Cell341Cell342Cell343Cell344Cell345Cell346Cell347Cell348Cell349Cell350Cell351Cell352Cell353Cell354Cell355Cell356Cell357Cell358Cell359Cell360Cell361Cell362Cell363Cell364Cell365Cell366Cell367Cell368Cell369Cell370Cell371Cell372Cell373Cell374Cell375Cell376Cell377Cell378Cell379Cell380Cell381Cell382Cell383Cell384Cell385Cell386Cell387Cell388Cell389Cell390Cell391Cell392Cell393Cell394Cell395Cell396Cell397Cell398Cell399Cell400Cell401Cell402Cell403Cell404Cell405Cell406Cell407Cell408Cell409Cell410Cell411Cell412Cell413Cell414Cell415Cell416Cell417Cell418Cell419Cell420Cell421Cell422Cell423Cell424Cell425Cell426Cell427Cell428Cell429Cell430Cell431Cell432Cell433Cell434Cell435Title   @}"P  NTitle   $@~"P  OTitle  p@ d.  T @ $@y W~ < " 7z!?@ABC89:;<=7}~|{vwxyz=<789:;6501234/.)*+,-('"#$%&! porpsila` porpsilaf<E porpsilar porpsilax& l& l& l&#X/<  dm6n=oDpKqRrYs`tgunvuew|x789':/; 7y>O?W@_A gDEFzG JKLM {PQRS V W |X Y '< ?=GB oCwH IN O}T UZ /[ 7\?]G^O_W`_~agbocwdefghijklmnopqrstuvwxy'z/f |7}?~G OgW _!g"o#w$% h   '/7?GOW_gowi       j$k*l0Cell1Cell2Cell3Cell4Cell5Cell6Cell7Cell8Cell9Cell10Cell11Cell12Cell13Cell14Cell15Cell16Cell17Cell18Cell19Cell20Cell21Cell22Cell23Cell24Cell25Cell26Cell27Cell28Cell29Cell30Cell31Cell32Cell33Cell34Cell35Cell36Cell37Cell38Cell39Cell40Cell123Cell212Cell213Cell214Cell215Cell216Cell252Cell253Cell220Cell221Cell222Cell223Cell254Cell255Cell227Cell228Cell229Cell230Cell256Cell257Cell234Cell235Cell236Cell237Cell258Cell259Cell241Cell242Cell243Cell244Cell260Cell261Cell248Cell249Cell250Cell251Cell262Cell263Cell264Cell265Cell266Cell267Cell268Cell270Cell271Cell272Cell273Cell274Cell276Cell277Cell278Cell279Cell280Cell282Cell283Cell284Cell285Cell286Cell288Cell289Cell290Cell291Cell292Cell294Cell295Cell296Cell297Cell298Cell299Cell301Cell302Cell303Cell304Cell434Cell435Cell436Cell437Cell438Cell439Cell440Cell247Cell570Cell571Cell572Cell573Cell574Cell575Cell576Cell577Cell578Cell579Cell580Cell581Cell582Cell583Cell584Cell585Cell586Cell587Cell588Cell589Cell590Cell591Cell592Cell593Cell594Cell595Cell596Cell597Cell598Cell599Cell600Cell601Cell602Cell147Cell603Cell74Cell604Cell605Cell606Cell607Cell608Cell609Cell610                         $ , 4 < D L  T \ d l t  |! " # $ $% & ' ( ) * + ,  - . +/ 0 1 2 3  4 5 $6 ,7 48 <29 D:  L; T< \= dv lw tx |y  z 9{ | } ~        @      $ ,G4<DLT\ dlt|hN U   \$,4< DLT\dlct | j  q $,4<DLT \xdlt|     $,4<DLT\ij$ k* '.5<CJQX_l0fmt{dCell1Cell2Cell3Cell4Cell5Cell6Cell7Cell8Cell9Cell10Cell11Cell12Cell13Cell14Cell15Cell16Cell17Cell18Cell19Cell20Cell21Cell22Cell23Cell24Cell25Cell26Cell27Cell28Cell29Cell30Cell31Cell32Cell33Cell34Cell35Cell36Cell37Cell38Cell39Cell40Cell41Cell42Cell43Cell44Cell45Cell46Cell47Cell48Cell49Cell50Cell51Cell52Cell53Cell54Cell55Cell56Cell57Cell58Cell59Cell60Cell61Cell62Cell63Cell64Cell65Cell66Cell67Cell68Cell69Cell70Cell71Cell72Cell73Cell74Cell75Cell76Cell77Cell78Cell79Cell80Cell81Cell82Cell83Cell84Cell85Cell86Cell87Cell88Cell89Cell90Cell91Cell92Cell93Cell94Cell95Cell96Cell97Cell98Cell99Cell100Cell101Cell102Cell103Cell104Cell105Cell106Cell107Cell108Cell109Cell110Cell111Cell112Cell113Cell114Cell115Cell116Cell117Cell118Cell119Cell120Cell121Cell122Cell123Cell124Cell125Cell126Cell127Cell128Cell129Cell130Cell131Cell132Cell133Cell134Cell135Cell136Cell137Cell138Cell139Cell140Cell141Cell142Cell143Cell144Cell145Cell146Cell147Cell148Cell149Cell150Cell151Cell152Cell153Cell154Cell155Cell156Cell157Cell158Cell159Cell160Cell161Cell162Cell163Cell164Cell165Cell166Cell167Cell168Cell169Cell170Cell171Cell172Cell173Cell174Cell175Cell176Cell177Cell178Cell179Cell180Cell181Cell182Cell183Cell184Cell185Cell186Cell187Cell188Cell189Cell190Cell191Cell192Cell193Cell194Cell195Cell196Cell197Cell198Cell199Cell200Cell201Cell202Cell203Cell204Cell205Cell206Cell207Cell208Cell209Cell210Cell211Cell212Cell213Cell214Cell215Cell216Cell252Cell253Cell220Cell221Cell222Cell223Cell254Cell255Cell227Cell228Cell229Cell230Cell256Cell257Cell234Cell235Cell236Cell237Cell258Cell259Cell241Cell242Cell243Cell244Cell260Cell261Cell248Cell249Cell250Cell251Cell262Cell263Cell264Cell265Cell266Cell267Cell268Cell270Cell271Cell272Cell273Cell274Cell276Cell277Cell278Cell279Cell280Cell282Cell283Cell284Cell285Cell286Cell288Cell289Cell290Cell291Cell292Cell294Cell295Cell296Cell297Cell298Cell299Cell301Cell302Cell303Cell304Cell305Cell306Cell307Cell308Cell309Cell310Cell311Cell312Cell313Cell314Cell315Cell316Cell317Cell318Cell319Cell320Cell321Cell322Cell323Cell324Cell325Cell326Cell327Cell328Cell329Cell330Cell331Cell332Cell333Cell334Cell335Cell336Cell337Cell338Cell339Cell340Cell341Cell342Cell343Cell344Cell345Cell346Cell347Cell348Cell349Cell350Cell351Cell352Cell353Cell354Cell355Cell356Cell357Cell358Cell359Cell360Cell361Cell362Cell363Cell364Cell365Cell366Cell367Cell368Cell369Cell370Cell371Cell372Cell373Cell374Cell375Cell376Cell377Cell378Cell379Cell380Cell381Cell382Cell383Cell384Cell385Cell386Cell387Cell388Cell389Cell390Cell391Cell392Cell393Cell394Cell395Cell396Cell397Cell398Cell399Cell400Cell401Cell402Cell403Cell404Cell405Cell406Cell407Cell408Cell409Cell410Cell411Cell412Cell413Cell414Cell415Cell416Cell417Cell418Cell419Cell420Cell421Cell422Cell423Cell424Cell425Cell426Cell427Cell428Cell429Cell430Cell431Cell432Cell433Cell434Cell435Cell436Cell437Cell438Cell439Cell440Cell441Cell442Cell443Cell444Cell445Cell446Cell447Cell448Cell449Cell450Cell451Cell452Cell453Cell454Cell455Cell456Cell457Cell458Cell459Cell460Cell461Cell462Cell463Cell464Cell465Cell466Cell467Cell468Cell469Cell470Cell471Cell472Cell473Cell474Cell475Cell476Cell477Cell478Cell479Cell480Cell481Cell482Cell483Cell484Cell485Cell486Cell487Cell488Cell489Cell490Cell491Cell492Cell493Cell494Cell495Cell496Cell497Cell498Cell499Cell500Cell501Cell502Cell503Cell504Cell505Cell506Cell507Cell508Cell509Cell510Cell511Cell512Cell513Cell514Cell515Cell516Cell517Cell518Cell519Cell520Cell521Cell522Cell523Cell524Cell525Cell526Cell527Cell528Cell529Cell530Cell531Cell532Cell533Cell534Cell535Cell536Cell537Cell538Cell539Cell540Cell541Cell542Cell543Cell544Cell545Cell546Cell547Cell548Cell549Cell550Cell551Cell552Cell553Cell554Cell555Cell556Cell557Cell558Cell559Cell560Cell561Cell562Cell563Cell564Cell565Cell566Cell567Cell568Cell569Cell247Cell570Cell571Cell572Cell573Cell574Cell575Cell576Cell577Cell578Cell579Cell580Cell581Cell582Cell583Cell584Cell585Cell586Cell587Cell588Cell589Cell590 e0 CE  'Dd NC`3Submit Dl 14446072003 HThT^&'1HTT"*mzEO"*zEO"*hTjV>"*njTV>"hhInTV>"%jV>"iIPc%P\IPcTV>"V>"F!dRxIiITZxIV>"wI 2>"{IdD F!dɫD֫D0  !bDM"OR@@@  @@X  DM" @@@  @@X  DM" @@@   @@X  DM" @@RbDM"OR@@X DM" 5Ol EMF. ("  %  Rp@Times New RomanXŁP*M0 33M03 Gtwwz Times New RomanQ0000w |00ץ00dv%  TT)n@I@LP -_888% '% V8SSSSSS% ( % (  % ZJ+,-./0123 4x36Cell237Cell258Cell259Cell241Cell242Cell243Cell244Cell260Cell261Cell248Cell249Cell250CZJl263Cell264Cell265Cell266Cell267Cell268Cell270Cell271Cell272Cell273Cell274Cell276ZJell279Cell280Cell282Cell283Cell284Cell285Cell286Cell288Cell289Cell290Cell291Cell292Cell294Cell295Cell296Cell297Cell298]Zj@@$`P  EARNED INCOME   T @ $ p# 11. Complete the following information for yourself and all household members working (including self-employment) in the Eligibility Month. The Eligibility Month is:  PP(TB P(BT a (TB,Arial (:'w11. Complete the following information for yourself and all household members working (including self-employment) in (F'8 the Eligibility Month. The Eligibility Month is:@ (from Section I, #9).   X   H&p 7Title  0@$@'!0 Title  0@@v"P  8Title  0 @w"P  9Title  0  @x"P  :Title  0 @y"P  ;Title  0 @z"P  <Title  0 $@{"P  =Title  @p@ a.    @$@(!0 Title  @@w"P  >Title   @x"P  ?Title    @y"P  @Title   @z"P  ATitle   @{"P  BTitle   $@|"P  CTitle  p@ b.    @p$@)!0 Title  @p@x"P  DTitle  p @y"P  ETitle   p @z"P  FTitle   p@{"P  GTitle  p @|"P  HTitle   p$@}"P  ITitle  p@ c.    p@ 0$@*!0 Title  p@ 0@y"P  JTitle  p 0 @z"P  KTitle  p 0 @{"P  LTitle  p 0@|"P  MTitle  p 0 @}"P  NTitle  p 0$@~"P  OTitle  p @@ d.     0@ $@+!0 Title   0@ @z"P  PTitle   0 @{"P  QTitle   0  @|"P  RTitle   0 @}"P  STitle  0 @~"P  TTitle   0 $@"P  UTitle   @p @ e.     @ $@,!0 Title   @ @{"P  VTitle    @|"P  WTitle    @}"P  XTitle    @~"P  YTitle    @"P  ZTitle   $@"P  [Title   p  f.     @0$P 0# HOW OFTEN PAIDKmG KGm (TB KmG,Arial (Z HOW OFTEN (aPAIDPP0 GROSS MONTHLY INCOME AMOUNTK{m {Km KmG K{m,Arial (ZGROSS MONTHLY (a INCOME AMOUNT  EMPLOYER'p p NAME0 p 0 p 0p"0 p 0p0p0 ~p 0 p P00 P HOURS PER MONTHKm Km a Km,Arial (Z HOURS PER (aMONTH @ P$ p P# 12. If not working in the Eligibility Month, complete the following information for yourself and all household members who have worked (including self-employment) at any time during the last 24 months.  rrI rI Km I,Arial ('|12. If not working in the Eligibility Month, complete the following information for yourself and all household members who ('U have worked (including self-employment) at any time during the last 24 months. p@0$@-!0 Title   p@0@|"P  \Title   p0 @}"P  ]Title   p 0@~"P  ^Title   p0`@"P  _Title   p`0$@"P  `Title   p@@ a.    0@$@.!0 Title  0@@}"P  aTitle  0 @~"P  bTitle  0 @"P  cTitle  0`@"P  dTitle  0`$@"P  eTitle  @p@ b.    @$@/!0 Title  @@~"P  fTitle   @"P  gTitle   @"P  hTitle  `@"P  iTitle  `$@"P  jTitle  p@ c.    @p$@0!0 Title  @p@"P  kTitle  p @"P  lTitle   p@"P  mTitle  p`@"P  nTitle  `p$@"P  oTitle  p@ d.    p@0$@1!0 Title  p@0@"P  pTitle  p0 @"P  qTitle  p 0@"P  rTitle  p0`@"P  sTitle  p`0$@"P  tTitle  p@@ e.    0@$@2!0 Title  0@@"P  uTitle  0 @"P  vTitle  0 @"P  wTitle  0`@"P  xTitle  0`$@"P  yTitle  @p f.     0 00 DATE LAST PAID8 ` DATE LAST WORKED' ' I ',Arial ( DATE LAST (WORKED p 0 p NAME `  `  `  `  `^ b `` `  0# CURRENT SOURCE OF INCOMEk P@ p$@$P UNEARNED INCOME   c @$pP"0 13. Complete the following section for all household members. I/We received money (unearned income) from the following sources in the Eligibility Month. The Eligibility Month is:  \\#O- \#-O a #O-,Arial (5'o13. Complete the following section for all household members. I/We received money (unearned income) from the (A'M following sources in the Eligibility Month. The Eligibility Month is:P! (from Section I, #9).   X `P0 H3p zTitle  @@$$@4!0 Title  @@$ @w"P  |Title  @ $@x"P  }Title  @$@y"P  ~Title  @$@z"P  Title  @$P@3"P  PTitle  * @P$$@3"P  PTitle  * @# 5>AMOUNT RECEIVED IN THE ELIGIBILITY MONTH IF DIFFERENT)+P PERSON WITH INCOMEOp   YES NO Pp p SOURCE  MONTHLY AMOUNTHj Hj #O- Hj,Arial (WMONTHLY (^AMOUNT@@$ @  @ @@@@N@RP@P$@.`$$`&@# 14. If you have no earned or unearned income, please explain how you met living expenses in the Eligibility Month. The Eligibility Month is  ..BnF .BFn Hj BnF,Arial (T&y14. If you have no earned or unearned income, please explain how you met living expenses in the Eligibility Month. The (`&Eligibility Month is% &@ (from Section I, #9).   X %`@&0  H5p Title  &P.P#@6&   & `&#  Explanation:   #c'7  0 MM/YYYYP ` MM/YYYY&P & @ MM/YYYY`P$ Public Assistance Unemployment Compensation (UC) Social Security Benefits (SSA) Supplemental Security Income (SSI) Railroad Benefits Retirement/Pension Child Support/Alimony Insurance Benefits Trust or Annuity Money from Roomers/Boarders/Renters Veteran's Benefits Labor & Industries Benefits (L&I) Military Allotment School Grants or Loans Cash Prizes (Bingo, Lottery, etc.) Money from Parents, Relatives, Friends Interest or Dividend Income Other Income Other Loans  \T \T a \T,Arial (n%Public Assistance (z%Unemployment Compensation (UC) (%Social Security Benefits (SSA) (%#Supplemental Security Income (SSI) (%Railroad Benefits (%Retirement/Pension (%Child Support/Alimony (%Insurance Benefits (%Trust or Annuity (%$Money from Roomers/Boarders/Renters (%Veteran's Benefits (%"Labor & Industries Benefits (L&I) (%Military Allotment ( %School Grants or Loans (%#Cash Prizes (Bingo, Lottery, etc.) ("%'Money from Parents, Relatives, Friends (.%Interest or Dividend Income (:% Other Income (F% Other Loans.@/` 5DECLARATION OF FINANCIAL STATUS DSHS 14-446 (07/2003)  \T ,Arial ($ DECLARATION OF FINANCIAL STATUS ($DSHS 14-446 (07/2003) 0`D  DOk as is   &  `D# DOk with correction   X 0`D !@ DAnother proof required   m 0D0@@ DApproving Signature O 0#`D 0#` 0@! DDate "P  Title  @@y"P  Title  @P@z"P  Title  P@$@{"P  Title   P@ P YES 6P@ P NO 4~ @@$@!0 Title  &@@ @w"P  Title  @ @x"P  Title  @@y"P  Title  @P@z"P  Title  @P$@{"P  Title  @ @ P YES . (@@ P NO +( @$@!0 Title  '@ @w"P  Title   @x"P  Title  @y"P  Title  P@z"P  Title  P$@{"P  Title   @  YES /n(@  NO 0@( @$@!0 Title  (@ @w"P  Title   @x"P  Title  @y"P  Title  P@z"P  Title  P$@{"P  Title   @  YES 0j(@  NO / ( @@$@!0 Title  )@@ @w"P  Title   @@x"P  Title  @@y"P  Title  @P@z"P  Title  P@$@{"P  Title   P@ P YES 5(P@ P NO 2( @@$@!0 Title  *@@ @w"P  Title  @ @x"P  Title  @@y"P  Title  @P@z"P  Title  @P$@{"P  Title  @ @ P YES 9(@@ P NO 6( @$@!0 Title  +@ @w"P  Title   @x"P  Title  @y"P  Title  P@z"P  Title  P$@{"P  Title   @  YES >*@  NO * @$@!0 Title  ,@ @w"P  Title   @x"P  Title  @y"P  Title  P@z"P  Title  P$@{"P  Title   @  YES :*@  NO * @@$@!0 Title  -@@ @w"P  Title   @@x"P  Title  @@y"P  Title  @P@z"P  Title  P@$@{"P  Title   P@ P YES *P@ P NO * @@ $@!0 Title  .@@ @w"P  Title  @ @x"P  Title  @ @y"P  Title  @ P@z"P  Title  @P $@{"P  Title  @ @ P  YES *@ @ P  NO *  @ $@!0 Title  / @ @w"P  Title   @x"P  Title    @y"P  Title    P@z"P  Title   P $@{"P  Title   @    YES 6*  @    NO *  @!$@!0 Title  0 @! @w"P  Title   !@x"P  Title   !@y"P  Title   !P@z"P  Title   P!$@{"P  Title   !@  ! YES 2* !@  ! NO * !@"@$@!0 Title  1!@"@ @w"P  Title  ! "@@x"P  Title  !"@@y"P  Title  !"@P@z"P  Title  !P"@$@{"P  Title  ! "P@ !"P YES Ӑ!"P@  !"P NO n "@@#$@!0 Title  2"@@# @w"P   Title  "@ #@x"P   Title  "@#@y"P   Title  "@#P@z"P   Title  "@P#$@{"P  Title  "@ #@ "P# YES ר"@#@ "P# NO N #@#$@!0 Title  3#@# @w"P  Title  # #@x"P  Title  ##@y"P  Title  ##P@z"P  Title  #P#$@{"P  Title  # #@ ## YES ##@ ## NO  #@$$@!0 Title  4#@$ @w"P  Title  # $@x"P  Title  #$@y"P  Title  #$P@z"P  Title  #P$$@{"P  Title  # $@ #$ YES #$@ #$ NO ؔ $@.`$.P/P 5DECLARATION OF FINANCIAL STATUS DSHS 00-000 (00/2003)   ,Arial (% DECLARATION OF FINANCIAL STATUS (%DSHS 00-000 (00/2003)$`&@# 14. If you have no earned or unearned income, please explain how you met living expenses in the Eligibility Month. The Eligibility Month is  ..BnF .BFn  BnF,Arial (T&y14. If you have no earned or unearned income, please explain how you met living expenses in the Eligibility Month. The (`&Eligibility Month is% &@ (from Section I, #9).  jX %`@&0  Hp Title  &P.P#@&   & `&#  Explanation:  l7  0 MM/YYYYP ` MM/YYYY&P & @ MM/YYYY`P$ Public Assistance Unemployment Compensation (UC) Social Security Benefits (SSA) Supplemental Security Income (SSI) Railroad Benefits Retirement/Pension Child Support/Alimony Insurance Benefits Trust or Annuity Money from Roomers/Boarders/Renters Veteran's Benefits Labor & Industries Benefits (L&I) Military Allotment School Grants or Loans Cash Prizes (Bingo, Lottery, etc.) Money from Parents, Relatives, Friends Interest or Dividend Income Other Income Other Loans  \T \T  \T,Arial (n%Public Assistance (z%Unemployment Compensation (UC) (%Social Security Benefits (SSA) (%#Supplemental Security Income (SSI) (%Railroad Benefits (%Retirement/Pension (%Child Support/Alimony (%Insurance Benefits (%Trust or Annuity (%$Money from Roomers/Boarders/Renters (%Veteran's Benefits (%"Labor & Industries Benefits (L&I) (%Military Allotment ( %School Grants or Loans (%#Cash Prizes (Bingo, Lottery, etc.) ("%'Money from Parents, Relatives, Friends (.%Interest or Dividend Income (:% Other Income (F% Other Loans0@# 0`D  DOk as is   T&  `D# DOk with correction   TX 0`D !@ DAnother proof required   Tm 0D0@@ DApproving Signature TO 0#`D 0#` 0@! DDate Te_4w0@$@:!0 Title  R0@ @"P   Title  0 @"P   Title  0@"P   Title  0@"P   Title  0P@7"P  `0Title  * 0P$@7"P  P Title  * @@$` @  RESOURCES   ? @$ p# 15. I/We, including children, owned or had a share in one or more of the following in the Eligibility Month. The Eligibility Month is:  00(TC 0(CT  (TC,Arial (:'15. I/We, including children, owned or had a share in one or more of the following in the Eligibility Month. The Eligibility (F' Month is:  (from Section I, #9).   X 0  H7p !Title   @ k>If you are age 17 or under and living with your parent(s), also list the resources of your parent(s) below.      @0$@8!0 Title  5@0 @"P  "Title   0@"P  #Title  0@"P  $Title  0@"P  %Title  0P@7"P  `0Title  * P0$@7"P   P Title  * #  WHERE LOCATED= PERSON WITH RESOURCE[@   YES NO p p RESOURCE(  TOTAL VALUE/@$    NRPP` Money on hand (cash) Checking Account Savings Account/Certificates of Deposit Credit Union Account Retirement Fund, IRA, KEOGH, etc. Money held by others Stocks/bonds/mutual funds Trust or annuity account Life Insurance Prepaid Funeral Plan (not life insurance) Money for funeral/burial Burial plots Sales contract Property on which you live Property on which you are not living Business Equipment (tools, machinery) Livestock (horses, cattle, sheep) Timber/crops Other:  bZ bZ (TC bZ,Arial (t&Money on hand (cash) (&Checking Account (&(Savings Account/Certificates of Deposit (&Credit Union Account (&"Retirement Fund, IRA, KEOGH, etc. (&Money held by others (&Stocks/bonds/mutual funds (&Trust or annuity account (&Life Insurance (&*Prepaid Funeral Plan (not life insurance) (&Money for funeral/burial (& Burial plots (&Sales contract (&Property on which you live (&%Property on which you are not living ((&&Business Equipment (tools, machinery) (4&"Livestock (horses, cattle, sheep) (@& Timber/crops (L&Other:0p @9  Title  @$0p"@ 16. I/We own or am (are) buying a car or other vehicle (truck, boat, motor home, snowmobile, motorcycle, etc.) or camper and/or trailer.  22Iu. 2I.u bZ Iu.,Arial (['t16. I/We own or am (are) buying a car or other vehicle (truck, boat, motor home, snowmobile, motorcycle, etc.) or (g' camper and/or trailer.  0@;    YES   ` 0@<    NO   ` 0 8If yes, list the item(s) even if not in your possession:    @$@=  Title  P@@  P ITEM*P@  @ OWNER OR BUYER*AP@  ` YEAR*@   MAKE*`@  P MODEL*` @  p VALUE* $@   #  AMOUNT OWEDcI cI a cI,Arial (tAMOUNT ({OWED@$P -17. I/We use a vehicle for medical purposes.    PP '18. I/We use a vehicle for employment.    @>  YES 0@?  NO "  If yes, list vehicle:    P !H@ Title  `@A ` YES 0`@B ` NO " P If yes, list vehicle:    P p@!HC Title  @ `$ pP  SIGNATURES   A  `@"@@D!   pP! BIRTH MOTHER'S SIGNATURE: &w `"@$@E!   p!# DATE: #"@@$ @F"  "PP" BIRTH FATHER'S SIGNATURE: &&u"@$ $@G"  "P"# DATE: #&$ @$$$@&p@H%0  $P%1 )PRIVATE AGENCY SOCIAL WORKER'S SIGNATURE: K&$&p$@I%0  $%1# DATE: #K 0 MM/YYYY.@/P 5DECLARATION OF FINANCIAL STATUS DSHS 14-446 (07/2003)  a ,Arial ($ DECLARATION OF FINANCIAL STATUS ($DSHS 14-446 (07/2003) ,Arial ($ DECLARATION OF FINANCIAL STATUS ($DSHS 14-446 (07/2003)`# DOk with correction   X @D` DAnother proof required   m nrpDppp 0 DApproving Signature Onr#Dpp# !@ DDate Title   0 P@"P  Title   0P $@"P  Title   0 @  @  YES |! 0 @  @  NO N!  @ $@!0 Title  D @ @"P  Title   @"P  Title    @"P  Title    P@"P  Title   P $@"P  Title   @    YES 8!  @    NO J!  @ p$@!0 Title  E @ p @"P  Title   p@"P  Title    p@"P  Title    pP@"P  Title   P p$@"P  Title   @    YES qV!  @    NO r!  p@0$@!0 Title  F p@0 @"P  Title   p 0@"P  Title   p0@"P  Title   p0P@"P  Title   pP0$@"P  Title   p @@  @ YES v! p@@  @ NO v! 0@$@!0 Title  G0@ @"P  Title  0 @"P  Title  0@"P  Title  0P@"P  Title  0P$@"P  Title  0 @ @ YES wd!0@ @ NO x6! @$@!0 Title  H@ @"P  Title   @"P  Title  @"P  Title  P@"P  Title  P$@"P  Title   @  YES z !@  NO y2! @p$@!0 Title  I@p @"P  Title   p@"P  Title  p@"P  Title  pP@"P  Title  Pp$@"P  Title   @  YES |N!@  NO }! p@0$@!0 Title  Jp@0 @"P  Title  p 0@"P  Title  p0@"P  Title  p0P@"P  Title  pP0$@"P  Title  p @@ @ YES p@@ @ NO  0@$@!0 Title  K0@ @"P  Title  0 @"P  Title  0@"P  Title  0P@"P  Title  0P$@"P  Title  0 @ @ YES 40@ @ NO  @$@!0 Title  L@ @"P  Title   @"P  Title  @"P  Title  P@"P  Title  P$@"P  Title   @  YES @  NO  @p$@!0 Title  M@p @"P  Title   p@"P  Title  p@"P  Title  pP@"P  Title  Pp$@"P  Title   @  YES @  NO  p@0$@!0 Title  Np@0 @"P  Title  p 0@"P  Title  p0@"P  Title  p0P@"P  Title  pP0$@"P  Title  p @@ @ YES p@@ @ NO  0 @ @ YES V0@ @ NO | ` Money on hand (cash) Checking Account Savings Account/Certificates of Deposit Credit Union Account Retirement Fund, IRA, KEOGH, etc. Money held by others Stocks/bonds/mutual funds Trust or annuity account Life Insurance Prepaid Funeral Plan (not life insurance) Money for funeral/burial Burial plots Sales contract Property on which you live Property on which you are not living Business Equipment (tools, machinery) Livestock (horses, cattle, sheep) Timber/crops Other:  bZ bZ  bZ,Arial (t&Money on hand (cash) (&Checking Account (&(Savings Account/Certificates of Deposit (&Credit Union Account (&"Retirement Fund, IRA, KEOGH, etc. (&Money held by others (&Stocks/bonds/mutual funds (&Trust or annuity account (&Life Insurance (&*Prepaid Funeral Plan (not life insurance) (&Money for funeral/burial (& Burial plots (&Sales contract (&Property on which you live (&%Property on which you are not living ((&&Business Equipment (tools, machinery) (4&"Livestock (horses, cattle, sheep) (@& Timber/crops (L&Other:0p @  Title  @$0p"@ 16. I/We own or am (are) buying a car or other vehicle (truck, boat, motor home, snowmobile, motorcycle, etc.) or camper and/or trailer.  22Iu. 2I.u bZ Iu.,Arial (['t16. I/We own or am (are) buying a car or other vehicle (truck, boat, motor home, snowmobile, motorcycle, etc.) or (g' camper and/or trailer.  0@    YES  0@    NO  0 8If yes, list the item(s) even if not in your possession:   @$@  Title  P@@  P ITEMoP@  @ OWNER OR BUYERoAP@  ` YEARo@   MAKEo`@  P MODELo` @  p VALUEo $@   #  AMOUNT OWEDcI cI Iu. cI,Arial (tAMOUNT ({OWED@$P -17. I/We use a vehicle for medical purposes.   PP '18. I/We use a vehicle for employment.   @  YES X0@  NO *  If yes, list vehicle:   P !H Title  `@ ` YES 0`@ ` NO  P If yes, list vehicle:   >P p@!H Title  @ `$ pP  SIGNATURES   A  `@"@@!   pP! BIRTH MOTHER'S SIGNATURE: $w `"@$@!   p!# DATE: z!"@@$ @"  "PP" BIRTH FATHER'S SIGNATURE: L!u"@$ $@"  "P"# DATE: !$ @$$$@&p@%0  $P%1 )PRIVATE AGENCY SOCIAL WORKER'S SIGNATURE: !$&p$@%0  $%1# DATE: ! 0 MM/YYYY4 # @D` DOk as is   (K& @pD`# DOk with correction   (KX @D` DAnother proof required   (Km nrpDppp 0 DApproving Signature (KOnr#Dpp# !@ DDate (Knr#Dpp# !@ DDate