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
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
09-653 Background Check Authorization
09-693 Declaration of Lawful Custody
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
09-741 Child Support Order Review Request
09-995 Companion Home Certification Evaluation (Developmental Disabilities Administration)
10-104B Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
10-210 Staff Statement of Qualifications
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
10-231 Adult Family Home (AFH) Referral Checklist (DDA)
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-238 Request for an Administrative Hearing (Residential Care Services)
10-244 Child and Family Engagement Plan (Developmental Disabilities)