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
14-057 Child Support Referral
14-057B Noncustodial Parent Child Support Enforcement Application
14-057D Child Support Referral Continuation
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-076 Change of Circumstances
14-078 Eligibility Review
14-084 Social Service Referral
14-105 Interview Appointment for Applicant (Community Services Division)
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-144A Medical Disability Decision
14-151 Request for DDA Eligibility Determination
14-155 Senior Citizens Service Application
14-223 Statement from School
14-224 Statement from Landlord/Manager
14-225 Acknowledgement of Services
14-252 Employment Verification
14-264 Application for Telecommunications Equipment
14-299 Adult Assessment Referral (Economic Services Administration)
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
14-332 Disability Assessment
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-349 Protective Payee Assessment
14-381 WorkFirst Individual Responsibility Plan
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2