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.
| Number(desc) | Form Name | File Format | |
|---|---|---|---|
| 06-162 | Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral | ||
| 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 |
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| 09-693 | Declaration of Lawful Custody |
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| 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) |
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| 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- |
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| 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) |
