DSS Form 2454 (NOV 09) qxd-2026

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  1. Click ‘Get Form’ to open the DSS Form 2454 in the editor.
  2. Begin by entering the Applicant/Recipient’s Name, Case No., and Case Name in Section I. This information is crucial for identifying the case.
  3. Next, provide the Fax Number and the Economic Services Worker’s Name to ensure proper communication with the county DSS.
  4. In Section II, select whether you are a Roomer or Boarder by checking the appropriate box. This helps clarify your relationship with the applicant/recipient.
  5. Fill in your payment details, including how much you pay and how often (Weekly, Biweekly, Monthly). Specify how many meals you eat per day with this household.
  6. Complete your Printed Name, Signature, Telephone No., and Date at the bottom of the form to validate your submission.

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