DSHS 27-109 – Applicant Affidavit Form

Jurisdiction: Country: United States | Province or State: Washington

What is a DSHS 27-109 – Applicant Affidavit Form?

The DSHS 27-109 is an “Applicant Affidavit” used by Washington State’s Department of Social and Health Services. You use it to make a sworn statement about facts that affect your case. It fills gaps when you do not have standard proof, or when DSHS needs a signed, detailed explanation in your own words. It becomes part of your case record and can be used to make eligibility, compliance, or service decisions.

The form is simple in concept. You identify yourself. You explain specific facts DSHS asked you to clarify. You attach any supporting documents you have. You sign under penalty of perjury. That signature is what makes it an affidavit rather than a casual statement. It tells DSHS you understand the importance of accuracy and that you stand behind your answers.

Who typically uses this form?

You will see it across DSHS programs. Applicants and clients for cash, food, child care, disability-related, and long-term services may use it. Parents and caregivers dealing with child support services may also use it. The form is widely used by people with limited documentation. This includes workers paid in cash, people experiencing homelessness, students, new residents without full records yet, and people in crisis.

Why would you need this form?

DSHS must verify certain facts before it can approve or adjust benefits and services. Sometimes standard documents are missing, delayed, or unsafe to obtain. Your employer may not give you a letter. Your landlord may be unresponsive. You may be fleeing abuse and cannot return to gather papers. You may be self-employed and do not have formal pay stubs. In these situations, an affidavit lets DSHS evaluate your statement as evidence.

Typical usage scenarios

• You explain a loss or reduction of income after recent job changes.
• You confirm you separated from a household member and no longer share food or money.
• You describe your shelter situation if you are couch surfing or unsheltered.
• You state childcare costs you pay in cash to a neighbor.
• You document resources that were stolen or destroyed.
• You verify that a child lives with you most of the time.
• You give information about a noncustodial parent to start a child support case when you lack formal records.

In each scenario, you swear the information is true and complete to the best of your knowledge.

The 27-109 does not grant benefits by itself. Instead, it completes your file. It gives your caseworker reliable, signed facts to process your case under program rules. When your affidavit is clear and detailed, your case moves faster. When it is vague, incomplete, or inconsistent, your case may be delayed while DSHS requests more information.

When Would You Use a DSHS 27-109 – Applicant Affidavit Form?

You would use this form when DSHS asks you to verify a fact and you do not have traditional proof, or when DSHS needs your sworn statement in addition to other documents. If you just started a job and do not have a pay stub yet, you can state your expected hours, rate, and start date. If you are self-employed, you can describe your business, how you get paid, and average monthly income and expenses. If you lost your wallet with your ID and bank card, you can explain what happened and when you requested replacements.

You also use the form when your living situation is hard to document. If you rent a room and your landlord will not provide a letter, you can describe the address, the amount you pay, to whom, and how often. If you stay temporarily with different friends, you can explain your shelter pattern and that you do not pay rent. If you live in your car or outdoors, you can say so directly. This helps DSHS decide shelter-related deductions and service referrals.

Parents and caregivers use the affidavit in child support contexts too. If you are applying for services and do not have the other parent’s details, you can share what you know. You can list possible addresses, employers, relatives, and any court orders you are aware of. If you fear harm and need to explain safety concerns, you can describe the situation. In some situations you may also complete other forms, but the affidavit captures your account in one sworn statement.

If you report a change that affects benefits, the affidavit can confirm the date and nature of the change. You can explain when employment ended, why, and whether you received final pay. You can note when a household member moved out and whether they still share expenses. You can clarify a one-time payment, like a tax refund or insurance payout, and how you used it.

Typical users

• Tenants
• Caregivers
• Parents
• Students
• Older adults
• Jobseekers
• Small business owners.

Landlords or employers do not use this form. This is your sworn statement. DSHS may later ask others for verification, but the affidavit comes from you.

You would not use the affidavit to replace documents that exist and are reasonably available. If you can get a pay stub, bank statement, or lease, that is usually better. The affidavit is most helpful when you cannot get proof through normal channels, when there is a timing issue, or when DSHS specifically asks for your statement.

Legal Characteristics of the DSHS 27-109 – Applicant Affidavit Form

The affidavit is legally binding because you sign it under penalty of perjury. In Washington, a signed statement that meets certain requirements has the same effect as a sworn declaration. Your signature confirms you understand that false statements can result in penalties. Those penalties can include overpayment recovery, case closures, disqualification from programs, and referral for prosecution in serious cases. This legal weight is why DSHS can rely on your affidavit to make decisions.

What ensures enforceability?

The structure of the form and the wording of the certification. The form asks for your identity, date, and place of signing, and it contains a clear perjury statement. Many DSHS affidavits do not require notarization because a properly executed perjury declaration is enough. In some settings, such as certain child support or court-related matters, DSHS may ask you to sign in front of a notary or in the presence of a caseworker. Follow the instruction on the form. If it says to notarize, do not sign until you are in front of the notary.

Your affidavit becomes part of the official case record. DSHS staff can use it to determine eligibility, calculate benefits, decide service levels, and enforce program requirements. If you request a hearing, your affidavit can be evidence. If your case involves child support, parts of your affidavit may be shared as allowed by law to locate a parent or establish and enforce support. Your information is still protected by confidentiality rules. DSHS limits disclosure to what is allowed for administration of programs and required by law.

Your obligation is to be truthful and complete. If you do not know a detail, say so. Do not guess if guessing would mislead. If an estimate is acceptable, label it as an estimate. If your situation changes after you sign, report the change as required for your program. Your signature captures your knowledge at the time of signing. Later changes do not make the original statement false, but failing to report changes can.

General legal considerations include identity matching, record retention, and data sharing within program rules. Include your DSHS client ID or case number to ensure your affidavit attaches to the correct case. Keep a copy of what you submit. Store it with your case papers. If you need accommodations, interpreter assistance, or large print, DSHS must provide equal access. Ask your worker before you sign if you need help understanding the form.

How to Fill Out a DSHS 27-109 – Applicant Affidavit Form

Approach the form like a short, factual report. Write clearly. Answer only what applies. Provide enough detail so a reader who does not know you can understand your situation.

Step 1: Gather your details and any supporting papers

Collect basic identifiers: your full legal name, date of birth, current address, phone, and email. Find your DSHS client ID and case number if you have them. Have your program information ready, such as Basic Food, TANF, ABD, child care, or child support. If you have documents that support your statement, keep them next to you. This could be a text from a landlord, a photo of a notice, a cash receipt, or a simple ledger of self-employment. If you cannot attach documents, plan to explain why.

Step 2: Complete the applicant information section

Enter your name exactly as it appears on your case. Provide your current mailing address and a safe phone number. If your address is unstable or unsafe, state that and give a reliable way to reach you. Note any preferred language or interpreter need if the form requests it. Include your DSHS client ID and the name of the program related to this affidavit. Accurate identity information keeps your affidavit tied to the right file.

Step 3: Identify the reason for your affidavit

Most 27-109 forms include a prompt or space for the issue you are addressing. Write a short heading, such as “Loss of income,” “Household composition,” “Shelter costs,” “Child care costs,” “Self-employment income,” “Child support information,” or “Safety concerns.” One affidavit can cover more than one topic, but keep topics organized. If you have unrelated issues, consider separate affidavits to avoid confusion.

Step 4: Write your statement of facts

Use plain language. Keep sentences short. Include dates, names, amounts, and locations. The goal is to answer who, what, when, where, and how. Here are examples by topic:

• Income change: “I was laid off from ABC Janitorial on August 29. I worked 25 hours per week at $18 per hour. My last day was August 29. I received my last paycheck on September 2 for 20 hours. I have no other work.”
• New job: “I started at Green Grocer on September 12. I will work 28 to 32 hours per week at $17 per hour. My first pay date is September 27. I do not have a pay stub yet.”
• Self-employment: “I do yard work. I am paid in cash. I work 10 to 15 hours weekly at $25 per hour. I buy fuel and tools. My average monthly expenses are $120. Attached is a 3‑month income and expense log.”
• Household changes: “John Doe moved out on July 15. He lives at 123 Pine Ave, Unit 6. He does not pay any of my bills. We do not share food. I pay my own expenses.”
• Shelter: “I rent a room at 88 West Street. I pay $600 on the first of each month to Maria Lopez in cash. I do not have a lease. Maria will not write a letter. I attached two cash receipt photos.”
• Homelessness: “I sleep in my car and sometimes at friends’ homes. I do not pay rent. I keep my mail at my sister’s apartment at 203 Maple Lane.”
• Child care: “I pay my neighbor, Kelly Nguyen, $25 per day for child care while I work. I pay in cash on Fridays. Average is $200 per month. Kelly does not give receipts. I can provide text messages.”
• Child support: “The other parent is Mark Rivera. Last known address was 422 Birch Rd in Tacoma in 2022. He worked at Coastal Lumber. His sister is Ana Rivera in Spokane. We never married. No court order. Our child has lived with me since birth.”
• Safety concerns: “I left due to domestic violence on May 6. It is not safe for me to contact my former partner for documents. I obtained a protection order on May 10. I cannot disclose my current address to him.”
• Resources: “My wallet was stolen on August 5. It had my EBT card and $70 cash. I filed a police report the same day. I requested a replacement card on August 6.”

Do not leave gaps. If you state no income, explain how you are meeting basic needs. If you are paid in cash, explain who pays you and how often. If a landlord refuses to write a letter, say so. If you cannot get a record because it puts you at risk, state the safety reason. Your goal is to give DSHS enough detail to verify your situation without guessing.

Step 5: List and attach supporting documents, if any

If you have anything that backs up your statement, list it and attach copies. Examples include screenshots of texts, photos of receipts, a letter from a friend or shelter, a calendar, or a simple ledger. Label each attachment with your name and the date. If you do not have documents, write why. For example: “Paid in cash. No receipts available. Employer will not provide letter.” DSHS weighs your affidavit along with any attachments.

Step 6: Read the certification and sign under penalty of perjury

Review the certification language near the signature block. Confirm your statement is true and complete to the best of your knowledge. Sign and date the form. Print your name clearly. If the form asks for the city and state where you signed, fill that in. If the form requires a notary, do not sign until you are in front of the notary. Bring photo ID if you have it. If you do not have ID, tell the notary or your caseworker in advance to plan an alternative.

Step 7: Include interpreter or assistor information, if used

If someone helped you complete the form, and there is a section to identify them, include their name and contact information. Note the language used if an interpreter helped. This helps DSHS understand how the statement was prepared and reach the assistor if clarification is needed.

Step 8: Complete the “Office Use Only” section, if directed

There may be a small area for DSHS staff. Do not fill it out unless your caseworker asks you to. If directed, include your worker’s name, office, and the date delivered. Otherwise, leave it blank.

Step 9: Make a copy and submit the affidavit

Make a copy or take clear photos of the completed form and any attachments. Keep them for your records. Submit the form as instructed by your caseworker. If you hand-deliver, ask for a date-stamped copy. If you submit electronically, confirm the file is legible. If you mail it, allow time for delivery and keep a note of the date you sent it.

Step 10: Respond to any follow-up

DSHS may accept your affidavit as submitted or may ask follow-up questions. Respond promptly. If DSHS needs a specific record, try to get it or explain why you cannot. If you realize you made a mistake, contact your caseworker and correct it in writing. If your situation changes after submission, report the change as your program requires.

Practical pointers to strengthen your affidavit

• Be consistent. Your dates and amounts should align with prior statements and known facts. If a date is approximate, say “approximately” and explain why.
• Be specific. “I pay rent” is weak. “I pay $600 cash on the first to Maria Lopez at 88 West Street” is strong.
• Be complete. Answer all parts of the issue. If the question is about income, include hours, rate, pay schedule, and start or end dates.
• Be honest about uncertainty. If you do not know the exact amount, provide a reasonable range and label it as an estimate.
• Be safety-minded. If contacting someone puts you at risk, state that clearly. DSHS can use alternative verification when safety is an issue.

Common situations and how to frame them

• Zero income: Explain how you are meeting food and shelter needs. Mention any support from family or friends, even if irregular. Note if support is temporary. Example: “My sister lets me stay without rent through October. She buys groceries. I am applying for jobs.”
• Irregular cash work: Describe the type of work, who hires you, typical hours, and pay per job. Include an average for the month. Keep a simple log going forward.
• No lease or landlord letter: Describe the unit, the name of the person you pay, the payment amount and frequency, and method (cash, app, money order). If you can, attach a screenshot of a payment app or a message.
• Students: Note your enrollment status (half-time, full-time), program, expected graduation date, and whether you get work-study or other income. Include whether you pay for meals and housing.
• Child support information: Provide as many locating details as you can. Old addresses, past employers, vehicle details, social media handles, family members, and service in the military can be helpful leads.
• Medical or disability-related statements: Focus on facts about functional limits that affect work or daily living, not medical opinions. Example: “I cannot stand more than 15 minutes due to back pain. I have appointments scheduled on [dates].”

What to avoid

Do not leave blanks in required areas. Do not exaggerate or understate facts. Do not rely on vague terms like “sometimes” or “a lot” without context. Do not submit originals unless instructed; send copies. Do not sign for anyone else. If you are a representative, state your authority and attach proof if required.

After you submit

Track your case deadlines. If the affidavit was requested to avoid a denial or closure, confirm DSHS received it on time. If you receive a notice based on information that is wrong or incomplete, request clarification and, if needed, submit an updated affidavit. Keep your copy. You may need it for a hearing or to address a future question.

The DSHS 27-109 is your voice in the record. Use it to tell your story with facts. When you write clearly, include dates and amounts, and sign under penalty of perjury, you give DSHS what it needs to move your case forward.

Legal Terms You Might Encounter

• Affidavit means a written statement you sign to confirm it is true. On this form, you swear that everything you listed is accurate to the best of your knowledge.
• Declarant is you, the person who signs the affidavit. If someone signs for you, that person becomes the declarant and must state their authority to sign.
• Oath or affirmation is the act of promising your statement is true. You do this when you sign the affidavit. If a notary is required, you take the oath in front of them. If a notary is not required, your signature is still a sworn promise under the form’s perjury statement.
• Penalty of perjury means you can face legal consequences if you knowingly give false information. The form includes a statement warning you about this. Read it carefully before you sign.
• Personal knowledge means you are stating facts you know directly. Do not include guesses or hearsay. If you are unsure about a date or amount, say so and explain how you estimated.
• Material fact is any detail that could affect a decision about your case. Income, household members, residence, or work hours are material facts. Leaving out a material fact can be treated like giving false information.
• Supporting documentation means records that prove what you state in the affidavit. Think of pay stubs, award letters, bank statements, lease agreements, or identification. If you rely on documents in your statement, attach copies and refer to them in the form.
• Authorized representative is someone you allow to act for you. If an authorized representative signs the affidavit, they must have written permission or legal authority. They should note their role and the basis of their authority on the form.
• Household composition refers to the people who live with you and share expenses. This matters if your benefits or services depend on who lives in your home. List household members consistently across all documents.
• Amended affidavit is a new affidavit that corrects or updates a prior one. If you discover an error, complete a new form, mark it as amended, and explain what changed. This keeps your file clear and current.

FAQs

Do you need a notary to sign this affidavit?

Not always. Some versions of this affidavit include a perjury statement and do not need a notary. Others require a notary or an authorized witness. Check the signature block on your form. If it mentions a notary, do not sign until you are in front of one. If it only includes a perjury statement, you can sign and date it yourself.

Can you sign electronically?

That depends on how the form is being submitted. Some offices accept typed signatures or electronic signatures through secure systems. Others require a wet ink signature. Look at any submission instructions you received. If you are unsure, ask your assigned worker whether an electronic signature is acceptable for this form.

Can someone else sign for you?

Yes, if they are your authorized representative or have legal authority, such as a power of attorney. The person signing must print their name, state their relationship to you, and note their authority to sign. They must also have personal knowledge of the facts or clearly state which parts are based on information you provided.

What if you do not know an exact date or amount?

Do not guess blindly. Use the best information you have. Say “on or about” with a month and year, or state a range if needed. Explain how you arrived at the figure. If you can, attach a document that supports your estimate, like a pay stub or letter.

What if you make a mistake after you sign?

If the form has not been submitted, fill out a fresh copy and sign again. If it has already been submitted, prepare an amended affidavit. Clearly label it “Amended,” reference the date of the original affidavit, and describe the correction. Submit it to the same office or worker who requested the form.

Do you need to attach proof with the affidavit?

If your statement relies on facts that can be verified with documents, attach them. For example, if you list income, include recent pay stubs. If you describe a living arrangement, include a lease or a letter from the landlord. Write “See attached” in the relevant section and number your pages.

How long is the affidavit valid?

Your affidavit reflects facts as of the date you sign it. If your situation changes, the affidavit does not update itself. You may need to submit a new affidavit or notify your worker in writing. Do not rely on an old affidavit to prove current facts.

Can you leave sections blank?

Avoid blanks. If a question does not apply, write “N/A.” If you do not know the answer, write “Unknown” and explain why. Unanswered sections can delay processing or trigger follow-up requests.

Checklist: Before, During, and After the DSHS 27-109 – Applicant Affidavit Form

Before signing

• Confirm why you were asked for the affidavit and what period it should cover.
• Gather identification for yourself and, if applicable, your representative.
• Have your case number and any related reference numbers.
• List your current address, phone, and email.
• Collect proof of income: pay stubs, award letters, self-employment logs.
• Collect proof of resources: bank statements, benefit cards, vehicle titles.
• Collect proof of housing: lease, mortgage statement, or landlord letter.
• Collect proof of household: names, birthdates, and relationships of members.
• Gather any notices, letters, or determinations related to the issue.
• If you will use a notary, bring a valid ID and do not sign in advance.
• If you need more space, prepare a separate page with your name and case number.

During signing

• Verify your name, case number, and contact details are correct and consistent.
• Read every question and answer fully. Do not skip sections.
• Use clear dates. Write months as numbers to avoid confusion.
• State amounts precisely. If estimating, say so and explain briefly.
• Refer to attachments in your answers. Example: “See Attachment A, Pay Stubs.”
• Number each attachment and write your name and case number on each page.
• Review the perjury statement above the signature line.
• If a notary is required, sign only in front of the notary.
• Date your signature. Ensure the notary date matches your signing date.
• If you correct a line, draw a single line through the error, write the correction, and initial it. Avoid white-out.
• If a representative signs, they must print their title and their authority to sign.

After signing

• Make a complete copy of the signed affidavit and all attachments for your records.
• Submit the affidavit using the method requested in your instructions.
• If you deliver it in person, ask for a date-stamped copy.
• If you send it by mail, keep proof of mailing and a list of enclosures.
• If you upload it, save the confirmation screen or message.
• Notify your worker that you submitted the affidavit, especially if there is a deadline.
• Watch for follow-up requests and respond quickly.
• Store your copy in a secure place for at least a year, or longer if your case is ongoing.
• If your situation changes, submit an updated affidavit or written notice.
• If you realize an error after submission, file an amended affidavit right away.

Common Mistakes to Avoid

• Leaving blanks or vague answers. Don’t leave any section empty. Blanks cause delays and follow-up calls. Write “N/A” when it does not apply, or “Unknown” with a short reason.
• Guessing without explanation. Don’t guess dates or dollar amounts with no context. If you must estimate, explain how you estimated and attach what you used, like a pay stub or bank record.
• Forgetting attachments or mismatching them. Don’t say “see attached” and then forget to include the document. Number every attachment and reference the number in your answer. Missing proof can lead to a denial or a new deadline.
• Signing before a notary is present. Don’t sign early if a notary is required. You will need to re-sign, which can cause missed deadlines.
• Using white-out or making illegible corrections. Don’t use correction fluid. Cross out the error with a single line, write the correction, and initial. Messy changes can lead to questions about authenticity.
• Inconsistent information across forms. Don’t state one income on the affidavit and another on your application. Inconsistencies trigger verification checks and can raise concerns about accuracy.
• Ignoring the perjury statement. Don’t rush the signature. False statements can lead to penalties and could affect your eligibility.

What to Do After Filling Out the Form

1. Submit the affidavit as instructed in your request letter or by your worker. Use the specific office or channel that handles your case. This helps your affidavit reach the correct file quickly.
2. Confirm receipt. If you deliver it in person, ask for a stamped copy. If you mail it, keep proof of mailing and note the date sent. If you upload it, save the confirmation. Then send a short message or call to confirm that it arrived and is legible.
3. Track deadlines. Write down any due date you were given. Put reminders on your calendar for one week before and two days before the deadline. If you need more time, ask before the due date.
4. Respond to follow-up requests. You may receive a request for more details or documents. Respond quickly and reference your affidavit date. If you need more time to get a document, explain what you are doing and when you can provide it.
5. Handle corrections with an amended affidavit. If you find an error, complete a new affidavit. Write “Amended” at the top, include the original signing date for reference, and clearly state what changed. Attach any updated proof.
6. Update the agency if your situation changes. Do not wait for a renewal. If your income, household, address, or resources change, send a written update or a new affidavit. State the date the change took effect and provide proof.
7. Keep your records organized. Store your signed affidavit, attachments, mailing proof, and any confirmations together. Label the folder with the date and topic. Good records save time during reviews or renewals.
8. Share copies only when needed. Keep your personal information secure. Provide the affidavit only to the office or worker who requested it, or to your authorized representative. If another part of your case needs it, confirm whether a duplicate is required or if your file can be shared internally.
9. Plan for renewals or reviews. Note when your case will be reviewed. Affidavits are often requested during changes or reviews. Having your documents organized makes the next request easier.
10. Ask questions early. If instructions are unclear, contact your worker or the office that requested the form. A quick question now can prevent delays later.
11. Prepare for interviews or calls. Your affidavit may be used to guide an interview. Keep your copy handy. If asked about a detail, refer to the page and attachment where it appears. Clear answers help move your case forward.
12. If you use an interpreter or representative. Tell the office when you submit the affidavit. Include the person’s name and contact information. This reduces delays and helps schedule any follow-up.
13. Safeguard sensitive information. The affidavit may include personal numbers or financial data. If you send it by mail, use a sealed envelope and note the addressee. If you upload it, use secure channels only. Avoid sending scans over unsecured email unless instructed.
14. Know when to submit new evidence. If you receive new proof that supports your affidavit, send it with a short cover note. Reference your affidavit date and case number. Timely updates can speed up a decision.
15. Expect a written decision or next steps. After review, you should receive a notice or a message that explains the outcome or what else is needed. Keep that notice with your affidavit records.
16. If your affidavit supports a specific claim or change. Make sure your narrative is clear and chronological. If the form did not give you enough space, attach a short statement page. Title it with your name, case number, and topic. Clear timelines reduce follow-up.
17. If you work irregular hours or have variable income. Keep a simple income log going forward. Note dates worked, hours, and gross pay. When asked again for an affidavit, you can attach that log and recent pay stubs for a complete picture.
18. If you are self-employed. Maintain a monthly ledger of income and expenses. Attach a summary for the months covered by your affidavit, plus bank statements if requested. Explain any cash transactions or deposits.
19. If you share housing costs. Clarify who pays what. If you split rent or utilities, state how much you pay and how you pay it. If a roommate pays the landlord directly, say so. Attach a lease page or a letter if available.
20. If your affidavit involves child care or medical costs. Provide receipts or statements that show the date, amount, and provider. State whether anyone else helps pay these costs. Include contact information for the provider if the agency needs to verify.
21. If you do not have a document you usually would. Explain why, and offer an alternative. For example, if you cannot get a letter from a prior employer, provide a bank statement showing deposits and a brief note about your employment dates.
22. If you move after submitting the affidavit. Send a written address update right away. Include your case number and the date you moved. Mail routing delays can affect your benefits or services.
23. If you receive a notice that seems inconsistent with your affidavit. Compare your copy to the notice. If a key fact was missed, send a short written response with your affidavit attached. Ask that your file be updated and confirm receipt.
24. If you withdraw or close your case. Keep your affidavit copy and any closure notice. You may need them if you reapply later. Copies help show prior facts and can speed up new reviews.
25. In short, submit the affidavit on time, keep proof, respond to requests, and update facts as they change. When in doubt, send a short note with your case number that explains what you are doing and why. Clear communication helps your file move without delays.