Applications and Forms

The Department of Social Services has suspended in-person visits to our field offices as a protective measure for customers and staff. We are continuing to provide services. Customers can access benefit and application information, 24/7, at www.connect.ct.gov and www.ct.gov/dss/apply; or 1-855-6-CONNECT. Full information on ways to contact DSS online, by phone, by mail, and at office dropboxes is at www.ct.gov/dss/fieldoffices. Information and updates about child support is available at www.ct.gov/dss/childsupport. Please also visit www.ct.gov/coronavirus for latest State of Connecticut updates; and www.ct.gov/dss/covid for DSS-specific updates. Thank you.

Applications and Forms

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Acquired Brain Injury (ABI) Waiver Request Form W-1130

Application for Acquired Brain Injury (ABI) Waiver Request.
Acquired Brain Injury (ABI) Waiver Request Form W-1130S - Versión en Español

Application for Acquired Brain Injury (ABI) Waiver Request - Versión en Español.
Application for Benefits (W-1E)
Application for Benefits (W-1ES) - Spanish

Application for Benefits (W-1ES) - Spanish
Bulk Ordering of Forms

To order bulk quantities of DSS forms, please follow this link to our Forms Requisition Site.
Certificate for Disclosure of Gross Wages, Salary or Commission Paid W-35

Certificate for Disclosure of Gross Wages, Salary or Commission Paid
CHCPE Request for Referral - Spanish W-1487S

CHCPE Request for Referral - Spanish
CHCPE Request for Referral W-1487

CHCPE Request for Referral
Client Supplement for Medical Information W-303

Client Supplement for Medical Information.
Client Supplement for Medical Information W-303S - Versión en Español

Client Supplement for Medical Information - Versión en Español.
Confidentiality and Non-disclosure Agreement for Contractor Employees W-1077C

Confidentiality and Non-disclosure Agreement for Contractor Employees.
Department of Social Services Electronic Health Screen W-1506web

Department of Social Services Electronic Health Screen.
Determination of Spousal Assets W-1-SA

This form is for use by individuals requesting an assessment of spousal assets when one spouse starts a continuous period of institutionalization of 30 or more days in a medical institution, long term care facility, or begins receiving home and community based services.
Determination of Spousal Assets W-1-SAS - Versión en Español

Aplicación para la Determinación de Bienes Personales del Esposo (de la Esposa)
Eligibility Re-determination Document W-1ER

Eligibility Re-determination Document

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Connecticut State Department of Social Services

Applications and Forms