FOR OFFICE USE ONLY

Application for Benefits DATE RECEIVED INITIALS

Check this box if you need help filling out this form. 02-07-2023 12:14 PM

1. FIRST NAME MIDDLE INITIAL LAST NAME SIGNATURE (REQUIRED) 2. CLIENT ID NUMBER (IF KNOWN)
William T Smotherman William t Smotherman;Jessica l ripley
3. STREET ADDRESS WHERE YOU LIVE CITY STATE ZIP CODE 4. HOME/PREFERRED PHONE NUMBER

10033 DES MOINES MEMORIAL DR S UNIT C BURIEN WA 98168-1623

5. MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE 6. OTHER PHONE NUMBER(S)

206-395-7748
8. I am applying for (check all that apply): 7. EMAIL ADDRESS
Cash Food [email protected]
Health Care Coverage (Everyone applying is
Nursing Home
65 or older, blind, or disabled)
Assisted Living Facility / Adult Family Home Medicare Savings Program
Hospice Healthcare / Workers with Disabilities (HWD)
In-Home Long Term Care Services Child Care Subsidy Programs
Other

9. I or someone in my household(check for all that apply): Are in a domestic violence situation Can't work because of health
problems Have a disability Are pregnant; due date: -
10. How much money do you expect your household to get this month? $ 450.00
11. How much money does your household have in cash and bank accounts? $ 0.00
12. How much does your household pay for rent or mortgage? $ 400.00
13. What utilities does your household pay for? Heating/cooling Telephone Other: Electricity
14. Is anyone in your household a seasonal or migrant farm worker? YES NO
15. If applying for food assistance, how many people in your household do you buy and prepare food for? 3
FOR OFFICE USE ONLY - Household eligible for expedited service: Yes No Screener's Initials: Date:
16. I need an interpreter. I speak: or sign; translate my letters into:
17. List everyone in your household even if you are not applying for them (attach additional sheets, if necessary).
CHECK OPTIONAL FOR NON-APPLICANTS
HOW
IF YOU
IS THIS
NAME DATE OF WANT SOCIAL CHECK TRIBE NAME(For
GENDER PERSON RACE
(FIRST, MIDDLE, LAST) BIRTH BENEFITS SECURITY IF U.S. American Indian,
RELATED NUMBER CITIZEN
(SEE SAMPLES BELOW)
Alaskan Natives)
FOR THIS
TO YOU?
PERSON
William T Smotherman M Self 02-25-1992 534-27-1861 White,
Jessica L Ripley F Spouse 11-14-1986 393-96-0828 White,
18. My ethnic background is Hispanic or Latino: YES NO
Race and Ethnic background information is voluntary and will not affect eligibility or benefit amounts. This information is used to assure program
benefits are distributed without regard to race, color, or national origin. For Food Assistance the USDA requires us to answer for you if no
information is provided.
Race examples:
White, Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, or any combination of races.

waconnection-WEB 14-001 (REV. 08/2016) Page 1

 I. General Information
1. In the past 30 days, I got cash, food, or medical assistance from another state, tribe, or other source. YES NO
2. Someone I'm applying for lives outside Washington State: YES NO Who:
3. I or someone in my household is a sponsored alien: YES NO Who:
4. I or someone in my household age 16 or older is in (check all that apply):
High School Equivalency Program High School College Trade School Who:

5. Someone is temporarily out of my home YES NO Who: Hallie-rose M Wilson

6. I or someone in my home has served in the U.S. Armed Forces, National Guard, or Reserves or been a dependent or spouse of someone
who has served: YES NO Who:
7. I am or someone I'm applying for is fleeing from the law to avoid going to court or jail for a felony crime: YES NO
8. I am living in: My own house or apartment Group Home Other other
Facility (list type): Date entered:
9. I am: Single Married Divorced Separated Widowed In a Registered Domestic Partnership
Legally Separated Married-Living Apart
10. I or someone in my home was convicted of trading Food Assistance for drugs after September 22, 1996: YES NO
11. I or someone in my home was convicted of buying or selling Food Assistance over $500 after September 22,1996: YES NO
12. I or someone in my home was convicted of trading Food Assistance for guns, ammunitions, or explosives after September 22, 1996:
YES NO
13. I or someone in my home was convicted of getting Food Assistance in more than one State after September 22, 1996: YES NO
14. I or someone in my home is: a. On Strike: YES NO b. A boarder: YES NO
II. Health Insurance Information (Not Needed for Basic Food)
I, my spouse, or someone in my household (check appropriate box):
1. Plan to enter, are in, or recently left a medical facility (such as a hospital or nursing home) YES NO
2. Do you need help with unpaid medical bills for any of the past three months? YES NO
3. Have health insurance:
NAME
INSURANCE TYPE POLICY DETAILS
(FIRST, MIDDLE, LAST)

III. Resources (Provide Proof; Cash Only)

A resource is anything you own or are buying that can be sold, traded, or converted into cash or money held by others. A resource does not
include personal property such as furniture, or clothing. Examples of resources are:
• Cash • Mutual funds • Houses, including the one • Life insurance
• Checking accounts • Stocks • you live in • Burial funds, prepaid plans
• Savings accounts • Annuities • Condominium • College funds
• CDs • Trusts • Land • Time-share
• Money market account • IRA • Sales contracts • Business equipment
• Savings bonds • 401K • Building • Farm equipment
• Bonds • Retirement fund • Life estate • Livestock

1. Please list the resources you, your spouse, or anyone you are applying for owns or is buying:
RESOURCE WHO OWNS LOCATION AMOUNT

2. I, my spouse, or someone I'm applying for have cars, trucks, vans, boats, RVs, trailers, or other motor vehicles:
YEAR CHECK IF VEHICLE IS USED
MAKE (E.G., FORD) MODEL (E.G., ESCORT) CHECK IF LEASED AMOUNT OWED
(E.G., 1980) FOR MEDICAL PURPOSE

3. I, my spouse, or someone I'm applying for has sold, traded, given away, or transferred a resource in the last five years (including trusts,
vehicles or life estates): YES NO If yes, what: and when:
TRANSFERRED FROM RESOURCE TYPE TRANSFERRED TO CASH VALUE DATE TRANSFERRED

waconnection-WEB 14-001 (REV. 08/2016) Page 2

APPLICANT'S NAME SOCIAL SECURITY NUMBER CLIENT IDENTIFICATION NUMBER
William T Smotherman 534-27-1861
IV. Annuities (Investments made by any household member to receive regular payments now or in the future.)
WHO OWNS THE ANNUITY? COMPANY OR INSTITUTION? AMOUNT OR VALUE MONTHLY INCOME DATE PURCHASED

If you, or your spouse, have an interest in an annuity and you accept Medicaid Long Term Care benefits, you must name the State of
Washington as a remainder beneficiary of the annuity.
V. Earned Income (Provide Proof)
1. I, my spouse, or someone I'm applying for had a job that ended in the past 30 days: YES NO
2. I, my spouse, or someone I'm applying for has income from work: YES NO If yes, please complete this section:
How much do you earn (before deductions)?
WHO EARNS THIS INCOME $ 100.00 every: Hour Day Week Every two weeks
William T Smotherman
Twice per month Month Year

EMPLOYER'S NAME AND PHONE NUMBER

Average hours you work per week:
Poached Jobs,instawork Etc. ;
START DATE
Days you work per week: 1.0
12-01-2022
Is this job self-employment? YES NO
st th
Pay dates (e.g., 1 and 15 , or every Friday): Weekly
How much do you earn (before deductions)?
WHO EARNS THIS INCOME $ 50.00 every: Hour Day Week Every two weeks
William T Smotherman
Twice per month Month Year

EMPLOYER'S NAME AND PHONE NUMBER

Average hours you work per week:
Mechanic Work/sidejobs ;
START DATE
Days you work per week: 1.0
01-01-2023
Is this job self-employment? YES NO
st th
Pay dates (e.g., 1 and 15 , or every Friday): Daily
VI. Other Income (Provide Proof, Use for all household members)
TYPE OF INCOME WHO GETS THE INCOME? GROSS MONTHLY AMOUNT

waconnection-WEB 14-001 (REV. 08/2016) Page 3

 VII. Monthly Expenses
RENT MORTGAGE SPACE RENT SUBSIDIZED HOUSING
$ 400.00 $ $ $
HOMEOWNER'S INSURANCE PROPERTY TAXES PROPERTY ASSESSMENTS OTHER FEES
$ $ $ $
What utilities does your household pay for separately from rent or mortgage?
Heat (Electric/Gas) Electric (Not Heat) Home/Cell Phone Water Sewer Garbage

Another person or agency, such as subsidized housing, helps me pay either all or part of these expenses: YES NO If yes:

Who What expense Amount they pay

I received a Low Income Home Energy Assistance Act (LIHEAA) payment in the past 12 months.
I, my spouse, or someone in my household pay or are supposed to pay:
Expense Type Monthly amount Who pays
Dependent care $ 200.00 Hallie-rose M Wilson

If you do not report any of the above listed expenses, we will consider this as a statement by your household that you do not want to receive a
deduction for this expense

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 VIII. Authorized Representative
An Authorized Representative is someone you allow DSHS to talk with about your benefits.
You can name someone, but you do not have to.
Do you have an Authorized Representative? YES NO

waconnection-WEB 14-001 (REV. 08/2016) Page 5

 IX. Additional Comments
Recently offered room at family members house for $400/month of able to pay. To clear up work income I work HOPFULLY 1 day aweek on a
day labor app making an average of $100 day/worked I also trade my mechanic know how for pay doing oil changes or similar small odd jobs
for around $50 maybe 3 jobs amonth. Hoping to get some help either with cash services to either help pay rent here or better yet I'd love to do
work first program/tanif anything to help I have a few options but no recorces to tale the routes I need tools for a few jobs I could take but no
money for tools or proper equipment needed like one particular job I could take now but need $380 in tools and $150 in safety gear of which I
don't have. Please anything tanif, emergency cash assistace FOOD is a MUST!

waconnection-WEB 14-001 (REV. 08/2016) Page 6

 Voter Registration
The Department offers voter registration services as required by the National Voter Registration Act of 1993. Applying to register or declining
to register to vote will not affect the services or amount of benefits that you may be provided by this agency. If you would like help
in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter
registration form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, your right
to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political
preference, you may file a complaint with: Washington State Elections Office PO Box 40229, Olympia, WA 98504-0229 (1-800-448-4881).

Do you want to register to vote or update your voter registration? Yes No

If you do not check either box, you will be considered to have decided not to register to vote at this time.
Declaration and Signatures
If applying for cash assistance, all adults (or authorized representatives) in the household must sign.
If applying for food assistance, the applicant (or authorized representative) must sign.
I understand I must:
● Give correct information and follow reporting requirements.
● Provide proof I am eligible.
● Assign certain rights to child support, to the State of Washington when I receive Temporary Assistance for Needy Families (TANF).
However, I can ask DSHS not to pursue child support if it would endanger me or my children.
● Cooperate with food assistance work requirements.

If I don't do these things, I may be denied benefits or have to pay them back.

I understand I can be criminally prosecuted if I willfully make a false statement or fail to report something I should report.

I authorize DSHS to contact other persons or agencies when necessary to help me get proof that I am eligible.

I have read or had explained to me my rights and responsibilities and received a copy of the Client Rights and Responsibilities, DSHS 14-113.
I certify or declare under penalty of perjury under the laws of the State of Washington that the information I gave in this application,
including the information concerning citizenship and alien status of the members applying for benefits, is true and correct.
APPLICANT'S SIGNATURE Date
eSigned by William t Smotherman 02-07-2023
OTHER ADULT APPLICANT'S SIGNATURE Date
eSigned by Jessica l ripley 02-07-2023
HELPER OR REPRESENTATIVE'S SIGNATURE Date
eSigned by No one 02-07-2023
WITNESS' SIGNATURE IF SIGNED WITH AN "X" Date

waconnection-WEB 14-001 (REV. 08/2016) Page 7

 CLIENT NAME (HEAD OF HOUSEHOLD)

Your Cash and Food Assistance William T Smotherman

CLIENT ID NUMBER
Rights and Responsibilities
Your Responsibilities (You Must)
 Give us the information we need to decide if you are eligible.
 Give us proof when it is needed. We may be able to get it for you. The information that you give the
department is subject to verification by federal and state officials. Verification can include follow-up contacts
from department staff including fraud investigators.
 Information reported to the Department of Social and Health Services may affect eligibility for health care
coverage administered by the Health Care Authority and the Health Benefit Exchange.
 Report changes (e.g. address, income, etc.) as required in WAC 388-418-0005. Report them by the 10th of the
next month.
 Cooperate with the Division of Child Support (DCS) if you accept a TANF grant. You must help DCS
establish, modify, or enforce child support for the child(ren) in your care, and establish paternity (if necessary).
You may refuse to cooperate with DCS if you can show that you have a good reason to believe that
cooperating with DCS puts you, your children, or the children in your care at risk of harm from the noncustodial
parent.
 Apply for and make a reasonable effort to get potential income from other sources when you ask for or receive
cash assistance.
 Complete required reports and reviews.
 Follow work requirements for cash assistance and food assistance.
 Tell us if you want someone else to use your food assistance on your behalf.
 Cooperate with our Quality Control reviews.
 Use food assistance only to buy food for the members of your household.
 Use cash assistance only for the benefit of members of your household.
 You must provide Social Security Numbers (SSN) or immigration status only for people applying for
assistance. If you 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.
Your Rights (We Must)
 Accept an application with your name, address, and signature or the signature of your authorized
representative.
 Help you fill out DSHS forms.
 Process your request for food assistance within 7 days if you qualify for expedited service.
 Give you a receipt if you ask for one when you provide documents.
 Give you a written decision, in most cases, within 30 days.
 You may refuse to speak to a Fraud Early Detection (FRED) investigator from the Office of Fraud and
Accountability. You do not have to let the investigator into your home. You may ask the investigator to come
back at another time. This will not affect your eligibility for assistance.
 You may ask for an administrative hearing if you disagree with a decision the department makes on my
case. You may also ask a supervisor or administrator to review the disputed decision or action without affecting
your rights to an administrative hearing.
 We must inform you of the 60-month time limit rule under the Temporary Assistance for Needy Families
(TANF) program. This time limit does not apply to your Basic Food, or child care subsidies.
Things You Should Know About your EBT Card
 Misuse of Benefits: Food and cash benefits distributed through the EBT card will provide DSHS with a history
of transactions where you have used your benefits. The department will use transaction information in
investigations of misuse of cash assistance benefits or the exchange of food assistance benefits for cash or
other items of value (trafficking).
 EBT card replacement: We may charge for replacement EBT cards. Keep your EBT card and your personal
identification number (PIN) safe and secure.
 High Balance EBT Cards: If you do not use your benefits for months at a time or accumulate a high balance
after several months, we may contact you to review your situation or your need for benefits.

DSHS 14-113 (REV. 12/2015) YOUR CASH AND FOOD RIGHTS AND RESPONSIBILITIES PAGE 1 OF 2
 Things You Should Know (Basic Food)
 We do send information about persons applying for Basic Food to other Federal agencies to check that the
information is correct. If any information is incorrect, the persons who apply may not get Basic Food. If a person
provides information that they know is incorrect, they could be criminally prosecuted. Penalties for intentionally
breaking Basic Food rules vary from disqualification from the program, to fines, or possibly imprisonment.
 If you sell, attempt to sell, exchange or donate your food assistance for anything of value such as cash,
drugs, weapons, or anything other than food from an authorized retailer (trafficking), you may be disqualified
from receiving food assistance benefits for a minimum period of one year up to a maximum lifetime
disqualification on the first offense. This disqualification continues even if you leave the State of Washington and
apply for benefits in another state.
 If you are required to participate in Basic Food work requirements, and fail to participate, you can be
disqualified for one month and until you comply with work requirements for the first failure; three months and until
you comply for the second failure; and six months and until you comply for the third time and each time
thereafter.
 You may be removed from the Basic Food program for breaking a Basic Food program rule as described in
the Basic Food penalty warning listed on this page.
 Report household expenses if you want the department to include these costs for Basic Food. If you
don’t report and provide proof of these expenses, then you are stating you don’t want us to use these expenses
to decide if you can get more Basic Food.
Things You Should Know (Cash)
 By getting Temporary Assistance for Needy Families (TANF) you assign your child and spousal support
rights to the Division of Child Support. This means that DCS may keep support owed to you, up to the amount of
the public assistance that you received. You must tell DCS immediately if you received child support
payments or benefits for the child while on TANF.
 If you stop getting TANF you must tell DCS about any changes that affect child support, such as the child
moved or my address changed.
 If you get TANF, you may ask for extra money to help pay for temporary emergency housing costs.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and
policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA
programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity
(including gender expression), sexual orientation, disability, age, marital status, family / parental status, income
derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any
program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint
filing deadlines vary by program.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille,
large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET
Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form,
AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a
letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of
the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
1. Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Ave, SW
Washington, D.C. 20250-9410;
2. Fax: (202) 690-7442; or
3. Email: [email protected]
USDA is an equal opportunity provider, employer, and lender.

By signing below, I am stating I have had my rights and responsibilities on receiving DSHS benefits and programs
explained to me. I understand if I refuse to sign this document it does not affect my eligibility but I am still held
responsible for program requirements and subject to program or criminal penalties that apply.
APPLICANT’S SIGNATURE DATE CO-APPLICANT’S SIGNATURE DATE
William t Smotherman 02/07/2023 Jessica l ripley 02/07/2023

DSHS STAFF ACES ID: Refused to sign.

DSHS 14-113 (REV. 12/2015) YOUR CASH AND FOOD RIGHTS AND RESPONSIBILITIES PAGE 2 OF 2
 CLIENT NAME (HEAD OF HOUSEHOLD)

Your DSHS Cash or William T Smotherman

CLIENT ID NUMBER
Food Benefits

DSHS Cash Grants

DSHS Food Benefits
TANF, Refugee Cash, ABD Cash, Diversion

Purpose Purpose
DSHS provides cash grants to low-income residents DSHS food assistance programs include:
who qualify for public assistance programs. • Basic Food.
These benefits help pay for basic living expenses • Food Assistance Program for legal
(RCW 74.04.770). immigrants (FAP).
• Washington Combined Application Project
TANF cash grants must be used only for the benefit of (WASHCAP).
children in your care. We can require proof you are
• Transitional Food Assistance (TFA).
using your TANF grant for the children’s needs (RCW
74.12.260). These programs provide assistance for low-
income people to buy food with electronic
benefits transfer (EBT) cards.
Appropriate Use
You may use your cash grant for living expenses
Appropriate Use
such as:
You, and your household, may use your food
• Shelter • Clothing benefits to buy food from a retailer authorized
• Fuel • Home maintenance by the USDA, Food and Nutrition Service
• Food • Personal hygiene (FNS).
• Transportation • Employment expenses
You may use your benefits to buy:
• Breads and cereals.
Illegal Use • Fruits and vegetables.
Under RCW 74.08.580, it’s not legal to use Electronic • Cheese, milk, and dairy products.
Benefit Transfer (EBT) cards or cash from EBT • Meats, fish, poultry, and eggs.
cards to: • Most food other than prepared hot foods.
• Gamble. Gambling includes lottery tickets, pull • Seeds and plants that produce food.
tabs, punch boards, bingo, horse racing, casino Illegal Use
games, and any game of chance found in RCW It is illegal to:
9.46, 67.16, and 67.70.
• Buy services in tattoo, body piercing, or body art • Use food benefits for anything other than to
shops. buy food for eligible household members.
• Buy cigarettes or tobacco. • Sell, or attempt to sell, your EBT card.
• Buy alcoholic items. • Exchange your benefits, or the food
• Buy goods or services in: purchased with your EBT card, for anything
o Taverns. of value (trafficking).
o Beer or wine shops unless authorized as a Examples of illegal trafficking include
SNAP or WIC retailer. exchanging food benefits for cash, drugs, or
o Nightclubs. weapons.
o Bail bond agencies. • Give your benefits to anyone who isn’t in
o Gambling establishments. your household.
o Adult entertainment venues with erotic • Use food benefits to buy non-food items.
performances. Examples include: cigarettes, tobacco, beer,
o Any place where someone under the age of 18 wine, liquor, household supplies, soap,
isn’t allowed paper products, vitamins, medicine, or pet
 For example, marijuana retailers where food.
marijuana and/or marijuana-based products • Use your food benefits to pay on credit
are sold. accounts.
YOUR DSHS CASH OR FOOD BENEFITS
DSHS 14-520 (REV. 06/2020)
 DSHS Cash Grants
DSHS Food Benefits
TANF, Refugee Cash, ABD Cash, Diversion

Penalty for Illegal Use Penalty for Illegal Use

If you use your EBT card or cash from your EBT card If you intentionally misuse your food benefits,
illegally or inappropriately, we may: you may be:
• Assign a protective payee to manage your cash • Required to repay any trafficked benefits.
grant.
• Disqualified and lose your benefits:
• Require proof you use your grant for the children in
o For at least one year.
your care.
o Up to a lifetime.
• Terminate your cash benefits.
• Pursue legal action, including criminal prosecution. o Be disqualified even if you move to
another state.
• Subject to fines.
Automated Teller machine (ATM) fees for EBT
Withdrawals • Subject to legal action, including criminal
prosecution.
When you use your EBT card to make cash
withdrawals at an ATM: DSHS will cooperate with state, local, and
federal authorities to prosecute trafficking of
• The ATM owner or bank operating the machine may
food benefits.
charge a surcharge fee.
• The department does not pay or reimburse for ATM
surcharge fees.
• You may be able to get cash back from some stores
without a fee.

By signing below, I agree that the appropriate and legal use of DSHS cash and food benefits have been explained.
I understand the proper use of benefits and the penalties for illegal use. I understand my eligibility for DSHS
benefits isn’t affected if I don’t sign this form. Anyone who fails to sign this form is still subject to program or
criminal penalties for illegal use of benefits.

I understand my EBT card provides DSHS with a history of my transactions, including where I use my card. I
understand DSHS will use this information, and my history of requests for replacement cards, to investigate
misuse of cash grants or food benefits.
APPLICANT’S SIGNATURE DATE

William t Smotherman 02/07/2023

Refused to sign; DSHS Staff Initial

DSHS 14-520 (REV. 06/2020)