Applications and Forms

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• Bulk Ordering of Forms

  To order bulk quantities of DSS forms, please follow this link to our Forms Requisition Site.

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

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

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

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

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

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

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

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

• W-1226

  Proof of Food Loss Form

• Therapeutic Diet Request W-351

  Therapeutic Diet Request.

• W-300SA

  W-300SA - Medical Report For SAGA Cash Benefits - Rev.12-19

• W-1225S

  Request for Replacement SNAP Benefits - Spanish

• W-650

  W-650 - Authorization for Reimbursement of Interim Assistance - Rev. 09/10

• W-0016RRS

  Client Rights and Responsibilities - W-0016RRS Rev 1-23 - Spanish

• W-0016RR

  Client Rights and Responsibilities - W-0016RR Rev 1-23 - English

• Patient Liability Change Report W-1696

  Patient Liability Change Report

• 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.

• W-682

  W-682 - DIRECT DEPOSIT AUTHORIZATION FORM - Rev. 1-23