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(asc) File Format
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
18-078 Application for Nonassistance Support Enforcement Services
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
12-206 Application for Disaster Food Benefits
12-207 Application for Disaster Cash Assistance
10-413 Application For Contract For Currently Licensed Assisted Living Facility
14-001 Application for Cash or Food Assistance
02-592 Application for Approval of Interpreter and Translator Continuing Education Activity
19-237 Application Budget Summary (Residential Care Services)
27-110 Applicant Request for a Copy of Background Check Information
15-331 Annual Assessment Checklist (Developmental Disability Administration)
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-269A Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration)
10-269 Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration)
10-679 Alternative Living Provider Application, Contracting, and Certification Overview Checklist (Developmental Disabilities Administration)
10-665 Alternative Living Provider Application (Developmental Disabilities Administration)
15-388 Alternative Living Certification Evaluation (Developmental Disabilities Administration)
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation
15-215 AFH Quality Improvement Visit Assessment
10-638 AFH Meaningful Day - Monthly Activities and Challenging Behavior Log
06-168 AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services)
06-169 AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services)
09-052 Affidavit of Forged Endorsement