Form W-1E "Application for Benefits" - Connecticut

What Is Form W-1E?

This is a legal form that was released by the Connecticut State Department of Social Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the Connecticut State Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form W-1E by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form W-1E "Application for Benefits" - Connecticut

774 times
Rate (4.7 / 5) 43 votes
State of Connecticut
Apply Faster Online!
Department of Social Services
W-1EINST
Visit www.connect.ct.gov
(Rev. 3/17)
instead of using this form.
W-1E Application for Benefits
Use this form to apply for Food, Cash or Medical help.
Read the instructions on the following pages and complete the form as directed.
ATTENTION!
If you speak another language, language assistance services, free of charge, are available to you.
Call 1-855-626-6632 or TTY: 1-800-842-4524.
Spanish (Español):
French (Français):
ATTENTION : Si vous parlez français, des services d'aide linguistique
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos
vous sont proposés gratuitement.
de asistencia lingüística.
Appelez le 1-855-626-6632 (TTY: 1-800-842-4524).
Llame al 1-855-626-6632 (TTY: 1-800-842-4524).
Polish (Polski):
Chinese (繁體中文):
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej
注意:如果 使用繁體中文, 可以免費獲得語言援助服務。
pomocy językowej.
請致電 1-855-626-6632 (TTY: 1-800-842-4524)。
Zadzwoń pod numer 1-855-626-6632 (TTY: 1-800-842-4524).
Vietnamese (Tiếng Việt):
Portuguese (Português):
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn
ATENÇÃO: Se fala português, encontram-se disponíveis serviços
phí dành cho bạn.
linguísticos, grátis.
Gọi số 1-855-626-6632 (TTY: 1-800-842-4524).
Ligue para 1-855-626-6632 (TTY: 1-800-842-4524).
Korean (한국어 ):
Italian (Italiano):
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili
용하실 수 있습니다. 1-855-626-6632
servizi di assistenza linguistica gratuiti.
(TTY: 1-800-842-4524) 번으로 전화해 주십시오.
Chiamare il numero 1-855-626-6632 (TTY: 1-800-842-4524).
Tagalog (Filipino):
Albanian (Shqip):
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të
ng mga serbisyo ng tulong sa wika nang walang bayad.
asistencës gjuhësore, pa pagesë.
Tumawag sa 1-855-626-6632 (TTY: 1-800-842-4524).
Telefononi në 1-855-626-6632 (TTY: 1-800-842-4524).
Russian (Русский):
Greek (ελληνικά):
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται
бесплатные услуги перевода.
υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν.
Звоните 1-855-626-6632 (телетайп: 1-800-842-4524).
Καλέστε 1-855-626-6632 (TTY: 1-800-842-4524).
Creole (Kreyòl Ayisyen):
‫اﻟﻌﺮﺑﻴﺔ‬
Arabic (
):
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki
‫ﻣﻠﺤﻮﻇﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﳌﺴﺎﻋﺪة اﻟﻠﻐﻮﻳﺔ‬
disponib gratis pou ou.
‫ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﳌﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ‬
Rele 1-855-626-6632 (TTY: 1-800-842-4524).
855-626-6632-1
:‫رﻗﻢ ﻫﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ‬
):
(800-842-4524-1
)
िह ं द ी
Hindi (
िह ं द ी
ध्यान दें : यिद आप
बोलते हैं तो आपके िलए मु फ्त में भाषा सहायता से व ाएं उपलब् ध हैं ।
पर कॉल करें ।
1-800-855-6632 (TTY: 1-800-842-4524)
Do not return these instruction pages with your
application form. Keep for your records or recycle.
Instructions Page 1 of 4
State of Connecticut
Apply Faster Online!
Department of Social Services
W-1EINST
Visit www.connect.ct.gov
(Rev. 3/17)
instead of using this form.
W-1E Application for Benefits
Use this form to apply for Food, Cash or Medical help.
Read the instructions on the following pages and complete the form as directed.
ATTENTION!
If you speak another language, language assistance services, free of charge, are available to you.
Call 1-855-626-6632 or TTY: 1-800-842-4524.
Spanish (Español):
French (Français):
ATTENTION : Si vous parlez français, des services d'aide linguistique
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos
vous sont proposés gratuitement.
de asistencia lingüística.
Appelez le 1-855-626-6632 (TTY: 1-800-842-4524).
Llame al 1-855-626-6632 (TTY: 1-800-842-4524).
Polish (Polski):
Chinese (繁體中文):
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej
注意:如果 使用繁體中文, 可以免費獲得語言援助服務。
pomocy językowej.
請致電 1-855-626-6632 (TTY: 1-800-842-4524)。
Zadzwoń pod numer 1-855-626-6632 (TTY: 1-800-842-4524).
Vietnamese (Tiếng Việt):
Portuguese (Português):
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn
ATENÇÃO: Se fala português, encontram-se disponíveis serviços
phí dành cho bạn.
linguísticos, grátis.
Gọi số 1-855-626-6632 (TTY: 1-800-842-4524).
Ligue para 1-855-626-6632 (TTY: 1-800-842-4524).
Korean (한국어 ):
Italian (Italiano):
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili
용하실 수 있습니다. 1-855-626-6632
servizi di assistenza linguistica gratuiti.
(TTY: 1-800-842-4524) 번으로 전화해 주십시오.
Chiamare il numero 1-855-626-6632 (TTY: 1-800-842-4524).
Tagalog (Filipino):
Albanian (Shqip):
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të
ng mga serbisyo ng tulong sa wika nang walang bayad.
asistencës gjuhësore, pa pagesë.
Tumawag sa 1-855-626-6632 (TTY: 1-800-842-4524).
Telefononi në 1-855-626-6632 (TTY: 1-800-842-4524).
Russian (Русский):
Greek (ελληνικά):
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται
бесплатные услуги перевода.
υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν.
Звоните 1-855-626-6632 (телетайп: 1-800-842-4524).
Καλέστε 1-855-626-6632 (TTY: 1-800-842-4524).
Creole (Kreyòl Ayisyen):
‫اﻟﻌﺮﺑﻴﺔ‬
Arabic (
):
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki
‫ﻣﻠﺤﻮﻇﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﳌﺴﺎﻋﺪة اﻟﻠﻐﻮﻳﺔ‬
disponib gratis pou ou.
‫ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﳌﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ‬
Rele 1-855-626-6632 (TTY: 1-800-842-4524).
855-626-6632-1
:‫رﻗﻢ ﻫﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ‬
):
(800-842-4524-1
)
िह ं द ी
Hindi (
िह ं द ी
ध्यान दें : यिद आप
बोलते हैं तो आपके िलए मु फ्त में भाषा सहायता से व ाएं उपलब् ध हैं ।
पर कॉल करें ।
1-800-855-6632 (TTY: 1-800-842-4524)
Do not return these instruction pages with your
application form. Keep for your records or recycle.
Instructions Page 1 of 4
Apply Faster Online
What happens next?
Apply faster online at connect.ct.gov. We will get your application
· Bring the application form to any DSS office or
sooner and you do not need to use this form.
mail it to:
DSS Scanning Center,
PO Box 1320, Manchester, CT 06045-1320
What can I apply for using this application form?
· We will review your application form and contact
· Help buying food (also called SNAP, the Supplemental Nutrition
you if we need more information. If you apply for
Assistance Program)
SNAP, you must complete an interview. We will try
calling you for an interview. You may also call the
· Cash help
Benefit Center to complete the interview after you
submit your application form. The Benefit Center
· Some types of medical help (health care coverage / HUSKY /
phone number is 855-626-6632.
Medicaid) - read next section for details.
· Temporary Family Assistance (TFA) applicants are
Who can use this application form?
required to have an in person office interview as a
condition of eligibility unless waived by the
Department.
· Anyone can apply for food (SNAP) or cash help using
this application form.
· Depending on what help you apply for, we may need
you to prove things that you tell us. See the next
· For medical help, use this application form only if the person who
page for more information about proofs.
needs help:
· is 65 or older, or
· has Medicare, or
When will I know if I am eligible?
· is blind or disabled.
· If you apply for SNAP, we may be able to give you
· To apply for long term care (nursing home) or home based care,
emergency assistance within 7 days of when you
apply online at connect.ct.gov, or in person at a DSS office, or
apply. To get emergency assistance, you must prove
using form W-1LTC. Call 855-626-6632 to ask for a W-1LTC form,
your identity and meet the following:
or get form W-1LTC at a DSS office.
· your household's total income is less than $150 a
month and your household's cash and bank
· To apply for all other types of medical help, apply online at
accounts total less than $100; or
AccessHealthCT.com or apply by phone at 855-805-4325, or use
· the total of your household's income, cash,
application form AH3. Call 855-805-4325 for the AH3 form, or get
and bank accounts are less than your total
the AH3 form at a DSS office.
housing and utility cost for a month; or
· there is a migrant or seasonal farm worker
How do I fill out this form?
in your household.
Use the icons (pictures) as a guide. Fill out the sections that match
· For SNAP applicants who are not eligible for
the icons for each program. The exclamation point means that all
emergency 7-day processing we will tell you within
programs need the information.
30 days if you are eligible. If the SNAP applicant is in
an institution and applying for SNAP and
Supplemental Security Income (SSI) at the same
· To apply for food help (SNAP) fill out all sections marked
time, the filing date is the date of release from the
institution. All SNAP applications are processed in
· To apply for cash assistance fill out all sections marked
accordance with SNAP procedures, even if you apply
for SNAP and other programs. You will not be denied
SNAP solely because you are denied benefits from
· To apply for medical help fill out all sections marked
other programs. If we decide you are eligible for
SNAP, your benefits usually start from the date we
· Complete all sections with an exclamation mark
receive your application form.
· You can apply for SNAP just by writing your name and address and
· If you apply for medical help, we will tell you our
decision within 45 days, except in unusual
signing on the first page. This will get your application started but
circumstances. If your eligibility is based on
we need answers to all SNAP questions to determine if you are
disability, we will make our decision within 90 days
eligible.
from when you apply.
· If you need help filling out this application form because of a
· If you apply for cash help, we will tell you if you are
disability or impairment, or if you need a translator, call
eligible within 45 days from when you applied.
1-855-626-6632.
Do not return these instruction pages with your
application form. Keep for your records or recycle.
Instructions Page 2 of 4
Do you have your proof documents?
You may have to provide us with copies of certain proofs (sometimes we call these verifications). Proof of identity, address,
social security numbers, citizenship status, income, assets, expenses, and more for each individual listed in the application form
may be necessary. The proofs we are looking for can include:
Household Members
Shelter and Utility Costs
· Birth certificates
· Lease
· Baptismal records
· Latest rent receipt
· Marriage papers
· Utility bill
· Divorce Papers
· Letter from your landlord
· Non-Citizen status resident card (I-551)
· Mortgage bill
· Arrival / Departure Form (I-94)
· Property tax bill
· Homeowner’s insurance policy
Income
· Pay stubs (proof of the last 4 weeks of wages)
Assets
· IRS form 1040 including all schedules
· Bank statements
· Bookkeeping records for self-employment
· Trust fund agreements
· Award Letter (for SSA or VA benefits, etc.)
· Stocks/bonds/U.S. savings bonds
· Life insurance policies
Medical Insurance and Expenses
· Letter from a financial institution
· Medical cards
· Car registration
· Medical bills
· Deeds
· Legal agreements
Child Support Costs
· Court order to pay child support
Students
· Cancelled checks
· Signed school verification letter (W-1446 - this is a DSS form)
· Wage withholding statements
· Report card or a statement from a school official (less than 30
· Statement from custodial parent of amount you pay
days old)
Send copies of these proofs in along with your application form. Providing us proof can help you receive your benefits
sooner. You can also bring them in person to a DSS office.
People who are deaf or hard of hearing and have a TDD/TTY device can contact DSS at 1-800-842-4524.
Persons who are blind or visually impaired can contact DSS at 1-860-424-5040.
For help with domestic violence, or to talk to someone, please call the Connecticut Coalition Against Domestic Violence
hotline at 1-888-774-2900.
Do not return these instruction pages with your
application form. Keep for your records or recycle.
Instructions Page 3 of 4
This page left blank intentionally
Do not return these instruction pages with your
application form. Keep for your records or recycle.
Instructions Page 4 of 4
Apply Faster Online!
State of Connecticut
Department of Social Services
W-1E Application for Benefits
W-1E
Visit www.connect.ct.gov
(Rev. 12/19)
instead of using this form.
Check one box.
Check all that apply.
Who are you applying for?
What kind of help are you applying for?
Complete all sections with this exclamation icon (picture).
Complete all sections that match the icons (pictures) for each program you select.
Only myself
Food (SNAP - Supplemental Nutrition Assistance Program)
Myself and my spouse
Cash
Myself and my family
Medical (HUSKY/ Medicaid/ health insurance)
Only children under 19 in my care
Special medical help to pay for unpaid medical bills from the past 3 months
Is anyone in the household pregnant?
Yes
No
Does anyone applying live in a licensed residential care facility (boarding home)?
Yes
No
Answer the following questions if you are applying for SNAP:
Complete sections with the apple icon (picture) if applying for food help.
Is your household's total income less than $150 a month (before taxes)?
Yes
No
Do your household's cash and bank accounts total less than $100?
Yes
No
Is the total of your household's monthly income, cash, and bank accounts less
Yes
No
than the total of your housing and utility costs for the month?
Is anyone in your household a migrant or seasonal farm worker?
Yes
No
Do you need a reasonable accommodation or extra help getting benefits because of a disability or impairment?
If yes, describe your condition
Yes
No
and the help you need.
Tell us about the people in your household, starting with yourself.
Person 1
My name (first, middle, last, suffix)
Legal or other name (if different)
Client ID (if known)
Social security number
Gender
Preferred spoken language
Do you need
Yes
No
an interpreter?
Date of birth
Best phone number
Phone
Home
Work
Cell
type
Home street address
City
State
Zip
No home
address
Mailing street address
City
State
Zip
Mailing address
(if different)
By signing, I agree that:
• I have read this form including the section about rights and responsibilities listed at the end of this application, or have had it read to me
in a language that I understand, and that I must comply with these rules;
• The information I am giving is true and complete to the best of my knowledge, including all information about citizenship, alien and felon status;
• I could go to prison or be required to pay fines if I knowingly give wrong or incomplete information; and
• DSS and other federal, state, and local officials may verify (check) any information I give.
If signing on behalf of the applicant, I am the:
Conservator,
Guardian,
Power of Attorney or already assigned authorized representative and
have attached supporting documentation. If you would like to designate an authorized representative, see page 2.
Print your or representative's full name
Signature
Date
Print full name of any other adult applicant
Signature
Date
W-1E Page 1 of 12
Page of 22