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
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-362A Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-365 Assisted Living Facility Resident Interview - Attachment G
10-361 Assisted Living Facility Resident List - Attachment C
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
17-292 Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
17-063 Authorization
27-130 Authorization for Alternate EBT Cardholder
09-415 Authorization for Expenditure (Non-Employee)
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
14-532 Authorized Representative
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
09-653 Background Check Authorization
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
12-008 Basic Food Affidavit Replacement for Household Disaster
11-034B Basic Food Eligibility Requirements: What You Need to Know
07-103 Basic Food Employment and Training (BFET) Participant Reimbursement
27-109 BCCU Applicant Affidavit
13-712 Behavioral Health Wraparound Support (BHWS) Request (Aging and Long-Term Support Administration (ALTSA)
17-300 BHA Personal Information Release (Behavioral Health Administration)