WA DSHS 17-041 2016 free printable template

Request for DSS Records A. Request for DSS Records By: NAME LAST FIRST MIDDLE TITLE ORGANIZATION OR BUSINESS NAME IF APPLICABLE MAILING ADDRESS CITY TELEPHONE NUMBER (INCLUDE AREA CODE) STATE FAX

How to fill out WA DSHS 17-041

How to fill out WA DSHS 17-041

1. Obtain a copy of the WA DSHS 17-041 form from the official DSHS website or your local office.
2. Carefully read the instructions provided on the form.
3. Fill in your personal information including your name, address, and contact details in the designated fields.
4. Provide information about your household members, including their names and relationship to you.
5. Complete the financial information section, detailing your income sources and amounts.
6. If applicable, check any boxes relevant to your circumstances or needs.
7. Review the completed form for accuracy and completeness.
8. Sign and date the form at the bottom.
9. Submit the form as directed, either by mail or in person.

Who needs WA DSHS 17-041?

1. Individuals or families seeking assistance from the Washington State Department of Social and Health Services (DSHS).
2. Those applying for public assistance programs such as food assistance, cash benefits, or medical coverage.
3. Applicants who need to report changes in circumstances that may affect their eligibility for benefits.

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What is WA DSHS 17-041?

WA DSHS 17-041 is a document used by the Washington State Department of Social and Health Services to report specific information related to financial assistance and services.

Who is required to file WA DSHS 17-041?

Individuals or organizations that receive or provide financial assistance or social services in Washington State are required to file WA DSHS 17-041.

How to fill out WA DSHS 17-041?

To fill out WA DSHS 17-041, gather the required information such as personal identification, income details, and service information, and complete the form by following the provided instructions and guidelines.

What is the purpose of WA DSHS 17-041?

The purpose of WA DSHS 17-041 is to ensure accurate reporting and tracking of financial assistance and services provided, helping to maintain accountability and program integrity.

What information must be reported on WA DSHS 17-041?

WA DSHS 17-041 must report information such as recipient identification, types of assistance received, financial details, and any relevant service information.