Publications

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• Medicare Savings Program Application W-1QMB

  Medicare Savings Program Application.

• W-944

  W-944 - Notice of Action - Rev. 05-23

• W-1226S

  Proof of Food Loss Form - Spanish

• W-1225

  Request for Replacement SNAP Benefits

• W-682

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

• 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-1226

  Proof of Food Loss Form

• W-300T19

  W-300T19 - Medical Report For Title XIX Disability Determination - Rev.12-19

• 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

• 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

• Bulk Ordering of Forms

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

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