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 Form Name(desc) File Format
02-569G Appendix G: State Agency Records Request (Research and Data Analysis)
02-569H Appendix H: Resource Requests (Research and Data Analysis)
02-569N Appendix N: Conflict of Interest Reporting (Research and Data Analysis)
02-569O Appendix N: Conflict of Interest Reporting for DSHS Employees Only (Research and Data Analysis)
27-110 Applicant Request for a Copy of Background Check Information
19-237 Application Budget Summary (Residential Care Services)
02-592 Application for Approval of Interpreter and Translator Continuing Education Activity
14-001 Application for Cash or Food Assistance
10-413 Application For Contract For Currently Licensed Assisted Living Facility
12-207 Application for Disaster Cash Assistance
12-206 Application for Disaster Food Benefits
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
18-078 Application for Nonassistance Support Enforcement Services
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-264 Application for Telecommunications Equipment
15-517 Application for Transition from Group Home to Group Training Home
11-022 Application for Vocational Rehabilitation Services
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
20-332 Appropriate Level of Forensic Services (ALFS) Screening Tool
27-272 Area Agency on Aging (AAA) Health-Related Social Needs (HRSN) Direct Service Approval
16-242 Ask DSHS
13-951 Aspiration / Choking Plan (Developmental Disabilities Administration)
14-492 Assessment Meeting Wrap-up
27-189 Asset Verification Authorization (Home and Community Services)