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
06-169 AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services)
06-171 Funding and Expenditure Data (Tribal)
06-172 Domestic Violence Prevention Account
06-173 Medical Evidence Reimbursement
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
06-184 Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services)
06-186 Financial Solvency Information (Aging and Long-Term Support Administration)
06-188 Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration)
06-189 Notice of Suspension of Supported Living Services (Developmental Disabilities Administration)
06-199 Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n
06-200 Registered Nurse (RN) Delegation Billing
07-081 Participation Reimbursement
07-098 Self Employment Monthly Sales and Expense Worksheet
07-103 Basic Food Employment and Training (BFET) Participant Reimbursement
07-103A Participant Reimbursement with Interpreter Declaration
07-104 Financial Communication to Social Services
07-107 Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration)
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
09-052 Affidavit of Forged Endorsement
09-280B Petition for Modification - Administrative Order
09-415 Authorization for Expenditure (Non-Employee)
09-508 Waiver of Statute of Limitations
09-520 Request for Conference Board