Tailored Supports for Older Adults

• 1. First name · optional

• Middle initial · optional

• Last name · optional

• 2. Client ID (if you know it) · optional

• 3. Address where you live · optional

• City · optional

• State · optional

• ZIP code · optional

• 4. Mailing address (if different) · optional · if it applies

• City · optional · if it applies

• State · optional · if it applies

• ZIP code · optional · if it applies

• 5. Primary phone number · optional

• 6. Secondary phone number · optional

• Home Cell Message · optional

  Home · Cell · Message

• Home Cell Message · optional

  Home · Cell · Message

• Check here if you do not have a caregiver · optional

  Check here if you do not have a caregiver

• 7. Name of your caregiver · optional · if it applies

• 8. Phone number · optional · if it applies

• 9. Address of caregiver · optional · if it applies

• City · optional · if it applies

• State · optional · if it applies

• ZIP code · optional · if it applies

• 10. Relationship to you · optional · if it applies

• Home Cell Message · optional · if it applies

  Home · Cell · Message

• 1. Do you have an authorized representative? · optional

  Yes · No

• 2. Do you want your authorized representative to receive letters from us about your application? · optional · if it applies

  Yes · No

• 3. Is your authorized representative also your legal guardian? · optional · if it applies

  Yes · No

• 4. Is your authorized representative also your power of attorney? · optional · if it applies

  Yes · No

• 5. Is your authorized representative also your caregiver? · optional · if it applies

  Yes · No

• If yes, who: · optional · if it applies

• If yes, who: · optional · if it applies

• 6. Authorized representative name/organization · optional · if it applies

• 7. Phone number · optional · if it applies

• 8. Mailing address of authorized representative · optional · if it applies

• IV. Marital Status · optional

  Not married · Married living with spouse · Married living apart from spouse · In a registered domestic partnership

• Name (First, middle, last) · optional

• Date of birth · optional

• Social Security number · optional

• Sex: M or F · optional

  M · F

• Check if you want services for this person · optional

  Check if you want services for this person

• Check if U.S. Citizen · optional

  Check if U.S. Citizen

• Race (see below) · optional

• Tribe name (for American Indians, Alaska Natives) · optional

• 1. My ethnic background is Hispanic or Latino: · optional

  Yes · No

• 2. My spouse or I is a sponsored alien? · optional

  Yes · No

• If yes, who? · optional · if it applies

• 3. I need an interpreter. I speak: · optional

• sign; · optional

  sign;

• translate my letters into: · optional

• 1. I have income from work? · optional

  Yes · No

• Employer’s name · optional · if it applies

• Employer’s phone · optional · if it applies

• Date I started this job · optional · if it applies

• Is this job self-employment? · optional · if it applies

  Yes · No

• Gross amount received (dollar amount before deductions) · optional · if it applies

• every: · optional · if it applies

  Hour · Week · Two weeks · Twice a month · Monthly

• Hours per week: · optional · if it applies

• Pay dates (e.g., 1st and 15th , or every Friday): · optional · if it applies

• 2. My spouse has income from work? · optional

  Yes · No

• Spouse’s employer’s name · optional · if it applies

• Spouse’s employer’s phone · optional · if it applies

• Date spouse started this job · optional · if it applies

• Is this job self-employment? · optional · if it applies

  Yes · No

• Gross amount received (dollar amount before deductions) · optional · if it applies

• every: · optional · if it applies

  Hour · Week · Two weeks · Twice a month · Monthly

• Hours per week: · optional · if it applies

• Pay dates (e.g., 1st and 15th , or every Friday): · optional · if it applies

• Do you want to register to vote or update your voter registration? · optional

  Yes · No

• Do you want to be automatically registered to vote? · optional · if it applies

  Yes · No

• Signature of Applicant or Authorized Representative

• Date

• Printed Name of Applicant or Authorized Representative · optional

Spouse: answered for each person (Name (First, middle, last), Date of birth, Social Security number, Sex: M or F, Check if you want services for this person, Check if U.S. Citizen, Race (see below), Tribe name (for American Indians, Alaska Natives)).

VIII. All Other Income (You or your spouse): answered for each person (Unearned Income Type, Who Gets the Income, Gross Monthly Amount).

IX. Resources: answered for each person (Resource Type, Who Owns, Location, Value).

VEHICLES: List any vehicles owned by you and your spouse.: answered for each person (Year (e.g., 2010), Make (Toyota), Model (Camry), Check if Leased, Amount Owed).

• Provide information or proof that the agency requests, report required changes within 30 days, and complete requested renewals.
• The printed form says a written decision is usually sent within 45 days. New TSOA enrollment is currently closed.
• If DSHS requests more information, you have 10 calendar days to provide it or ask for more time.
• You may ask for an administrative hearing if you disagree with a DSHS decision about TSOA eligibility.
• Read the approval letter to find which changes you must report.

• List only yourself and your spouse in the household table. Spouse Social Security number is optional if the spouse is not applying for TSOA.
• Race and ethnic background information is voluntary.
• American Indians and Alaska Natives do not have to report the income excluded in the earned income note.
• Required flags cover the printed signature requirement. Other fields are requested but the form does not clearly mark each field as mandatory. Ask HCS what is needed for your case.
• The form gives a 2020 revision and older contact routes. DSHS currently lists HCS intake at 877-429-7019.
• The relationship cells in the two household rows already say Myself and Spouse. They are fixed labels, not questions to answer.

• DSHS says TSOA is not currently accepting new clients. No reopening date is stated.
• Some details here could not be confirmed. Check with Washington Department of Social and Health Services before you apply.