Applications and Forms

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• Application for Benefits (W-1ES) - Spanish

  Application for Benefits (W-1ES) - Spanish - Latest Version

• Application for Benefits (W-1E) - English

  Application for Benefits (W-1E) - English - Latest Version

• HIPAA Authorization for Disclosure of Information W-298

  HIPAA Authorization for Disclosure of Information W-298

• HIPAA Authorization for Disclosure of Information W-298S

  HIPAA Authorization for Disclosure of Information W-298S

• W-1225

  Request for Replacement SNAP Benefits

• W-1226

  Proof of Food Loss Form

• W-1225S

  Request for Replacement SNAP Benefits - Spanish

• W-1226S

  Proof of Food Loss Form - Spanish

• Request for Exemption from the SNAP Time Limit (W1460) - English

  Request for Exemption from the SNAP Time Limit (W-1460) - English - Rev. 10/24

• Request for Exemption from the SNAP Time Limit (W1460S) - Spanish

  Request for Exemption from the SNAP Time Limit (W-1460S) - Spanish - Rev. 10/24

• Therapeutic Diet Request W-351

  Therapeutic Diet Request.

• Medicare Clearance Form W-9

  Medicare Clearance Form.

• Child Care in Connecticut - State Fiscal Year 2005-2006 (637 KB)

  DSS purchases child care spaces in the 19 priority school districts, 35 severe-need school communities, and 9 other towns.

• Vendor Direct Deposit Form W-260

  Vendor Direct Deposit Form

• 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.