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
14-443 Financial / Social Services Communication
14-449 Unmet Need Breakdown
14-453 Protective Payee Decision
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
14-463 Waiver Transportation Record (DDA)
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
14-467 Mid-Certification Review
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation
14-484 Nurse Delegation: Nursing Visit
14-489 SSIF Introduction Letter
14-491 NSA Representative Checklist forDDA Review
14-492 Assessment Meeting Wrap-up
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
14-495 Naturalization Letter
14-501 Community Resource Declaration
14-503 Interim Assistance Reimbursement Agreement Cover
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-515 Notice and Finding of Responsibility
14-517 DSHS Letter Requesting Non Work SSN
14-520 Your DSHS Cash or Food Assistance Benefits