Electronic DSHS Forms

The Electronic DSHS Forms page is a centralized repository where the public can find and download official forms for Washington Department of Social and Health Services programs.

You may download some DSHS forms. These are provided only if a DSHS program requests forms to be available electronically for public use. DSHS forms are available for electronic completion in different software; however, all DSHS forms below are available as Adobe Acrobat PDF files. This means you can open, view, and print each form. To open, view, and print PDF forms, you need to download the free Adobe Acrobat Reader.

We do our best to ensure the links below are accurate; but, if you find a link which does not work, please contact Forms and Records Management.

Number Form Name Form File
06-194 DPI Statement of Earnings (Division of Program Integrity)
06-195 DPI Statement of Income (Division of Program Integrity)
06-193 DPI Statement of Shared Housing Costs (Division of Program Integrity)
06-196 DPI Tribal Income Verification (Division of Program Integrity)
17-227 DSHS / HCA Systems Access Request
15-549 DSHS Adult Education Instructor Application (Home and Community Services)
17-253 DSHS Background Check System (BCS) Access Request
04-452A DSHS Community Services Customer Survey (Community Services Division)
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
14-517 DSHS Letter Requesting Non Work SSN