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ELIGIBILITY REVIEW FOR LONG TERM CARE BENEFITS CLIENT S NAME (First, Middle Initial, Last) CLIENT S ID NUMBER CLIENT S ADDRESS CITY STATE ZIP CODE CLIENT S MAILING ADDRESS CITY STATE ZIP CODE NOTE:
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What is dshs 14 416 form?
The DSHS 14-416 form is a form used by the Department of Social and Health Services (DSHS) in Washington State to report income and resources for the purpose of determining eligibility for various social service programs.
Who is required to file dshs 14 416 form?
Individuals or households applying for or receiving social service benefits from DSHS may be required to file the DSHS 14-416 form.
How to fill out dshs 14 416 form?
The DSHS 14-416 form can be filled out by providing accurate and detailed information about income, resources, and household members as requested on the form.
What is the purpose of dshs 14 416 form?
The purpose of the DSHS 14-416 form is to collect information to determine eligibility for social service programs such as food assistance, medical care, and cash assistance.
What information must be reported on dshs 14 416 form?
Information that must be reported on the DSHS 14-416 form includes income, resources, household composition, and other relevant financial information.
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