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.

Working Connections Child Care Application (form 14-417)

This link will take you to the start page for the Online Application. After you start the application, select  Child Care as the program you want to apply for.


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 formatTranslations.

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]

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  • Authorization to Release Information (form 17-063)

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

  • Child Support Enforcement Referral (form 14-057)

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

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

This form is completed at each Eligibility Review.
PDF formatTranslations.

  • 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 formatPDF formatTranslations.

  • Eligibility Review (form 14-078)

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

  • Fair Hearing Withdrawal (form 02-528)

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

  • 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 formatPDF formatTranslations.

  • 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 formatTranslations.

  • 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 formatTranslations.

  • 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 formatPDF formatTranslations.

  • 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 formatPDF formatTranslations.

  • 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 formatPDF formatTranslations.

  • 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 formatPDF formatTranslations.

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 formatTranslations.

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 formatTranslations.