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
18-176A Address Release Information Letter
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
18-398 Client Overpayment Notice
18-398A Vendor / Provider Overpayment Notice
18-398B Department of Children, Youth, and Families (DCYF) Client Overpayment Notice
18-399 Social Service Incorrect Payment Computation
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
18-433 Declaration of Support Payments (Division of Child Support)
18-463 New Hire Reporting Methods and Instructions (Division of Child Support)
18-464 Introduction to New Hire Reporting
18-483 Employer Payment Identification Instructions
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
18-544 Transmittal of Resident Personal Funds
18-551 School Statement
18-555 Financial Information Sheet
18-607 Child Care Verification
18-681 Request for Collection of Uninsured Health Care Expenses
18-682 Detail Sheet – Uninsured Health Care Expenses
18-700 Direct Deposit Authorization
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
18-720 Client Responsibility Notice (Home and Community Services)
19-074 Transfer / Loan / Recovery Agreement (Division of Vocational Rehabilitation)
19-237 Application Budget Summary (Residential Care Services)
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program