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
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
16-275 Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services)
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
17-295 Certification Evaluation Checklist for Companion Homes Providers (Home and Community Living Administration)
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
18-097 Statement of Resources and Expenses
18-433 Declaration of Support Payments (Division of Child Support)
18-720 Client Responsibility Notice (Home and Community Services)
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
27-155 Declaration on Commercial Purposes
27-189 Asset Verification Authorization (Home and Community Services)
27-207 Acknowledgement Statement (Meaningful Day) (Home and Community Services)
27-208 Declaration to Adult Protective Services
27-253 New Freedom Authorized Representative (Home and Community Services)
27-261 Integrated Settings Provider Attestation (Developmental Disabilities Community Services)