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(asc) Form Name File Format
27-225 DSHS Claim of Stolen EBT Benefits: Food (Community Services Division)
27-208 Declaration to Adult Protective Services
27-207 Acknowledgement Statement (Meaningful Day) (Home and Community Services)
27-203 Individual Provider (IP) Attestation of Informal Support (Home and Community Services)
27-192 Home and Community Services (HCS) Resumption of Training Attestation
27-189 Asset Verification Authorization (Home and Community Services)
27-155 Declaration on Commercial Purposes
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
18-720 Client Responsibility Notice (Home and Community Services)
18-433 Declaration of Support Payments (Division of Child Support)
18-097 Statement of Resources and Expenses
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
16-275 Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
16-266 Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration)
16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services)
16-253 For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services)
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
16-201 New Case / Resource Manager Assessment (Developmental Disabilities Administration)
16-199 New Case/Resource Manager Technology Training Checklist
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
15-591 High School Home Care Aide Instructor Application (Home and Community Services)
15-567 On-the-Job Facility Training Plan Application and Updates (Home and Community Services)