Electronic DSHS Forms

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.

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Number(desc) Form Name File Format
14-381 WorkFirst Individual Responsibility Plan
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
14-402 Notice to Parents (WorkFirst)
14-416 Eligibility Review for Long Term Services and Supports
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
14-427 Teen Parent Living Assessment
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
14-431A Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
14-432 Direct Deposit Enrollment
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-438 Stop Work
14-439 Washington State Combined Application Program (WASHCAP) Application
14-443 Financial / Social Services Communication
14-449 Unmet Need Breakdown
14-453 Protective Payee Decision
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
14-456 Physician Certification for Home Maintenance Allowance (HMA) (Home and Community Services)
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
14-463 Waiver Transportation Record (DDA)
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
14-467 Mid-Certification Review
14-473 Inventory for Client and Agency Planning (ICAP) Letter