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Get WA DSHS 14-393 2000-2024

Other people living at your address share the costs for food, rent, and utilities. Attach additional pages if needed. 1. CLIENT'S NAME 2. TELEPHONE NUMBER ( 4. STREET ADDRESS ) 3. TOTAL NUMBER OF PERSONS LIVING AT THIS ADDRESS - CITY STATE ZIP CODE 5. Complete the following information for all other ADULTS (age 18 and over) who live at your address: NAME SOCIAL SECURITY NUMBER SHARES FOOD COST RELATIONSHIP TO ME (SON, MOTHER, FRIEND, ETC.) BIRTHDATE YES COOKS OR EATS MEALS WITH ME.

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  • utilities
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