Apply for HFWF Programs

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Begin the Application Process Step 1.

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1. Select Assistance

		Cash
		Washington Basic Food Program
		Drug and Alcohol Treatment
		Medical
		Child Care
		Children's Medical
		Long term care assistance (Nursing home, in-home care and residential facility)

2. Please enter the following information.

		Enter user name here. This can be any name you want so long as you can remember it!

		Enter the number of people (including yourself) living at your address here.


		Enter a password of your choice (8 characters, no spaces) If you lose your connection or need to take a break at any time you can enter your password on the home page to continue your application. Make sure to write this password down.
		Enter your password again

		Check here if you are a third party provider such as a hospital or child care center entering information on behalf of someone else.

3. Carefully read the following statements and check the appropriate box
below, then hit continue:

Client Rights and Responsibilities:

I am responsible to:

* Give the information the department needs to decide if I am eligible for benefits. The information that I give the department is subject to verification by federal and state officials.  Verification can include follow-up contacts from department staff including fraud investigators.

* Provide proof when it is needed. If I have trouble getting proof, the department may help me get the proof or contact other persons or agencies for it.

* Report changes as required under WACs 388-418-0005 and 388-418-0007. If I get cash or food assistance, I must report changes within 10 days from the date I learn of the change. If I get medical assistance, I must report changes within 20 days from the date I learn of the change.

* Report shelter costs, child or dependent care, child support that is legally obligated, medical expenses, and self-employment expenses so the department can decide if I can get more food assistance. If I don't report and provide proof of these expenses, then I am stating I don't want the department to use these expenses to decide if I can get more food assistance.

* Complete any required reports and reviews when asked.

* Look for, get, and keep a job or participate in other activities if required for cash or food assistance.

* Cooperate in the collection of child support and medical support. I may refuse to cooperate with the collection of support if I fear the non-custodial parent may harm me, my children, or the children in my care.

* Let the department know if I want someone else to use my food assistance benefits on my behalf.

* Cooperate in the Quality Control review process.

I understand that:

* By getting Temporary Assistance for Needy Families(TANF)or medical care benefits, I assign certain rights to child or medical care support to the State of Washington.

* If I get TANF, I may ask for extra money to help me pay for temporary emergency housing costs.

* By law, if I am age 55 or older AND receive long-term care services, DSHS may recover from my estate (assets I own at the time of my death) to repay DSHS for the long-term care and for the medical services I received while getting long-term care. This is called ESTATE RECOVERY. Long-Term Care services include COPES, CAP, OBRA, CASA, Medicaid Personal Care, Nursing Home services, adult day health, and private duty nursing. Estate recovery does not occur until after my death and the death of my surviving spouse, if any. If I have dependent heirs, estate recovery may be delayed for some hardship reasons.

* I may be restricted to one physician and pharmacy if I misuse my medical benefits.

* I must provide Social Security Numbers (SSN)(1) or immigration status only for people applying for benefits. If I choose not to give SSNs or immigration status for non-applying household members, all household members'income and resources must still be verified if needed to determine eligibility.

* I may refuse to speak to a Fraud Early Detection(FRED)investigator from the Division of Fraud Investigation. I do not have to let the investigator into my home. I may ask the investigator to come back at another time. This will not affect my eligibility for benefits.

* I may be removed from the food stamp program for breaking a food stamp program rule as described in the food stamp penalty warnings listed on the second page of this form.

* I may ask for a fair hearing if I disagree with a decision the department makes on my case. I may also ask a supervisor or administrator to review the disputed decision or action without affecting my rights to a fair hearing.

(1)Social Security numbers provided will be used by state and federal agencies to check identity of household members, to verify eligibility, prevent duplicate participation, to collect claims, and to exchange information by computer with other agencies to monitor compliance with program regulations and for program management. This information may also be disclosed to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. Collection of social security numbers is authorized under the Food Stamp Act of 1977, as amended, 7 U. S. C. 2011-2036.

We are responsible to:

* Accept an application with your name, address, and signature the day you come in for any program DSHS offers.

* Help you fill out forms if you ask us for help.

* Process your request for Food Assistance within five (5)days if you qualify and have an emergent need for food.

* Give you a receipt when you leave an application or other materials with the department if you ask us for a receipt.

* Give you a written decision, in most cases, within 30 days. Medical and some disability cases may take 45 to 60 days. Pregnancy medical is authorized within 15 working days. 
 
* Give you at least 10 days to provide information needed to determine your eligibility. If you do not give us the information needed to determine eligibility or request additional time to give us the information, then we may deny your request for benefits.

* Send you a written notice, in most cases, at least 10 days before we make changes to lower or stop your benefits.

* Keep the information you give to us private. We may share some facts with other agencies for efficient management of federal programs.

* Encourage you to continue your application for food assistance even if you may not qualify for other assistance programs.

* Inform you that the 60 month time limit rule under the Temporary Assistance for Needy Families(TANF) program does not apply to your food assistance, medical, or child care benefits.

* Process your request for medical assistance even if you don't qualify for other assistance programs.

* Give you continued medical assistance while we decide if you are eligible for another medical program before we stop your benefits.

* Provide interpreter or translator services at no cost to you and without significant delay in getting your benefits.

* Assist you in registering to vote.

* Share your child's immunization history with the Child Profile Immunization Tracking System.

Food Stamp Penalty Warnings

We do send information about persons applying for food stamps to other Federal agencies to check that the information is correct. If any information is incorrect, the persons who apply may not get food stamps. If a person provides information that they know is incorrect, they could be criminally prosecuted. Penalties for intentionally breaking food stamp rules vary from disqualification from the program, to fines, or possibly imprisonment.

Food Stamp Work Requirement Penalty Warning

If I am required to participate in food stamp work requirements, and I fail to participate, I can be disqualified for one month and until I comply with work requirements for the first failure; three months and until I comply for the second failure; and six months and until I comply for the third time and each time thereafter.

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 discrimination on the basis of race,color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis or religion or political beliefs.

To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights,  Room 326-W, Whitten Building, 14th and Independence Avenue S. W., Washington, D. C. 20250-9410 or call (202)720-5964 (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)619-0403(voice)or (202)619-3257(TDD). USDA and HHS are equal opportunity providers and employers.

Child Care Assistance Warning:
I understand completing this form does not guarantee payment.  If child care is authorized, I agree to child care payment at my usual rate or the DSHS rate whichever is less.

I have read (or had explained to me) my rights and responsibilities. I declare under penalty of perjury that the information I am giving in this application is true, correct, and complete to the best of my knowledge. I understand that I can be criminally prosecuted if I incorrectly receive cash, food, or medical assistance because I have willfully made a false statement or willfully failed to report something I should report.

Yes - I have read these rights and responsibilities and agree to them.

No - I have read these rights and responsibilities but do not agree to them.

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