Applications and Forms

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• Personal Care Assistance (PCA) Waiver Request Form W-982S - Versión en Español

  Personal Care Assistance (PCA) Waiver Request Form - Versión en Español.

• Protective Services for the Elderly Report Form W-675

  Protective Services for the Elderly Report Form.

• Report of Admission or Discharge Rated Housing Facility/Residential Care Home W-265

  Form W-265 is used by the Rated Housing Facility/Residential Care Home to notify the Department (1) when an individual is admitted to the home or facility, (2) when an individual is discharged from the home or facility (regardless of whether the discharge is temporary or permanent) and (3) when there is a change in discharge status from temporary to permanent.

• SAGA Application for Payment of Funeral and Burial Expenses W-1053

  SAGA Application for Payment of Funeral and Burial Expenses.

• Self-Employment Income Verification Form W-38

  Self-Employment Income Verification Form.

• Self-Employment Income Verification Form W-38S - Versión en Español

  Self-Employment Income Verification Form (W-38S) - Versión en Español

• SNAP ABAWD Work Requirement Medical Report W-1210

  SNAP ABAWD Work Requirement Medical Report.

• Therapeutic Diet Request W-351

  Therapeutic Diet Request.

• Vendor Direct Deposit Form W-260

  Vendor Direct Deposit Form

• W-0016RR - Rights and Responsibilities

  Client Rights and Responsibilities

• W-0016RRS - Rights and Responsibilities

  Client Rights and Responsibilities - Spanish

• W-1225

  Request for Replacement SNAP Benefits

• W-1225S

  Request for Replacement SNAP Benefits - Spanish

• W-1226

  Proof of Food Loss Form

• W-1226S

  Proof of Food Loss Form - Spanish