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
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
06-186 Financial Solvency Information (Aging and Long-Term Support Administration)
06-189 Notice of Suspension of Supported Living Services (Developmental Disabilities Administration)
06-191 DPI College Financial Aid Request (Division of Program Integrity)
06-192 DPI Dividend and Interest Request (Division of Program Integrity)
06-193 DPI Statement of Shared Housing Costs (Division of Program Integrity)
06-194 DPI Statement of Earnings (Division of Program Integrity)
06-195 DPI Statement of Income (Division of Program Integrity)
06-196 DPI Tribal Income Verification (Division of Program Integrity)
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
09-052 Affidavit of Forged Endorsement
09-508 Waiver of Statute of Limitations
09-693 Declaration of Lawful Custody
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
10-210 Staff Statement of Qualifications
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-301 Notification of Enrollment Review (Developmental Disabilities Administration)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-348 Risk Assessment and Community Protection Program Information Checklist
10-351 Disclosure of Services Required by RCW 18.20.300
10-377 Notification of Age Four (4) Enrollment Expiration-
10-393A Cost Estimate Worksheet for Cochlear Implants (Division of Vocational Rehabilitation)
10-393B Cost Estimate Worksheet for Bone Anchored "Hearing Aid" Auditory Devices (BAHA) (Division of Vocational Rehabilitation)
10-400 Information Request Letter