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- Administrative Operations
- DGS Emergency Release Request Form 2015_11_18.pdf24.44 KBFebruary 14 2020
- DGS Emergency Release Request Form Instructions 2015_11_18.pdf58.65 KBFebruary 14 2020
- DGS Emergency Release Request Form 2015_11_18.pdf
- CSEA Forms
- Autorización de depósito directo de Manutención de Menores - 10.28.14.pdf66.91 KBFebruary 14 2020
- CSEA-Application-Form-980-980A.pdf417.91 KBFebruary 14 2020
- Direct Deposit Application Update - 02-04-22.docx31.6 KBFebruary 07 2022
- Direct Deposit Application Update - 04-01-24.docx32.05 KBApril 02 2024
- Direct Deposit Application Update - Spanish 02-04-22.docx34.94 KBFebruary 07 2022
- Direct Deposit Application Update - Spanish 04-01-24.docx35.39 KBApril 02 2024
- Financial-Statement-DR30.pdf82.22 KBFebruary 14 2020
- Motion for Modification ccdr006.pdf67.82 KBFebruary 14 2020
- New-Application-Form-980-980A-rev5-Rev-Spanish.pdf611.65 KBFebruary 14 2020
- Autorización de depósito directo de Manutención de Menores - 10.28.14.pdf
- FIA Forms
- Amharic
- To Apply for Assistance
- DHS_FIA_9711A Req-Assist Revised 3-2023_Amharic No highlights (1) (1).pdf759.16 KBApril 24 2023
- DHS_FIA_9711A Req-Assist Revised 3-2023_Amharic No highlights (1) (1).pdf
- To Apply for Assistance
- Arabic
- To Apply for Assistance
- DHS_FIA_9711Req-Assist Revised 3-2023_Arabic No highlights (1).pdf456.2 KBApril 24 2023
- DHS_FIA_9711Req-Assist Revised 3-2023_Arabic No highlights (1).pdf
- To Apply for Assistance
- Burmese
- To Apply for Assistance
- DHS_FIA_9711Req-Assist Revised 3-2023_Burmese No highlights (1).pdf807 KBApril 24 2023
- DHS_FIA_9711Req-Assist Revised 3-2023_Burmese No highlights (1).pdf
- To Apply for Assistance
- Chinese
- To Apply for Assistance
- DHS_FIA_9711 9711A Req-Assist Revised 3-2023_Chinese_Traditional No highlights (1).pdf762.04 KBApril 24 2023
- DHS_FIA_9711A Req-Assist Revised 3-2023_Chinese_Simplified No highlights (1).pdf2.09 MBApril 24 2023
- DHS_FIA_9711 9711A Req-Assist Revised 3-2023_Chinese_Traditional No highlights (1).pdf
- To Apply for Assistance
- English
- OHEP
- DHS-FIA-803-OHEP-Alimony-Child-Support-Form-English.pdf77.51 KBSeptember 23 2024
- DHS-FIA-804-OHEP-Concern-for-Personal-Safety-Privacy-Form-English.pdf91.72 KBSeptember 23 2024
- DHS-FIA-805-OHEP-Crisis-Season-Declaration-Form-English.pdf134.71 KBSeptember 23 2024
- DHS-FIA-806-OHEP-Declaration-of-Zero-Income-English.pdf77.54 KBOctober 08 2024
- DHS-FIA-807-OHEP-Household-Worksheet-English.pdf76.83 KBSeptember 23 2024
- DHS-FIA-808-OHEP-Income-Verification-of-Self-Employment-English.pdf84.26 KBSeptember 23 2024
- DHS-FIA-809-OHEP-Landlord-Agreement-English.pdf719.49 KBSeptember 23 2024
- DHS-FIA-810-OHEP-Physician-Certification-English.pdf57.3 KBSeptember 23 2024
- DHS-FIA-811-OHEP-Proxy-Authorization-Form-English.pdf68.72 KBSeptember 23 2024
- DHS-FIA-812-OHEP-Rent-–-Living-Arrangements-Form-English.pdf92.34 KBSeptember 23 2024
- DHS-FIA-813-OHEP-Resource-Provider-Statement-English.pdf74.22 KBSeptember 23 2024
- DHS-FIA-814-OHEP-Wage-Verification-English.pdf129.61 KBSeptember 23 2024
- DHS-FIA-9780-OHEP-Application-English-1.pdf630.74 KBSeptember 23 2024
- myDHS Fax Cover Sheet.pdf770.74 KBOctober 21 2024
- OHEP2025Application - Fillable.pdf642.16 KBOctober 21 2024
- DHS-FIA-803-OHEP-Alimony-Child-Support-Form-English.pdf
- Other-Forms
- 1 FIA Change Report Form
- DHS_FIA_491-Change-Report-form-7.2020.pdf253.4 KBMay 25 2023
- DHS_FIA_491-Change-Report-form-7.2020.pdf
- 2 Request for Information to Verify Eligibility
- DHS_FIA_1052 Req Verify11.19 (1) november 20.pdf29.59 KBMay 27 2020
- DHS_FIA_1052 Req Verify11.19 (1) november 20.pdf
- 3 Request Appeal for Hearing
- DHS_FIA_334-Request-For-Fair-Hearing-4.1.2021-fillable.pdf178.07 KBApril 29 2021
- DHS_FIA_334-Request-For-Fair-Hearing-4.1.2021-fillable.pdf
- 4 QMB and SLMB Programs
- 9705-DHS-QMB-SLMB-MSP-Application-Revised-August-2021.pdf274.09 KBAugust 09 2021
- Qualified_Medicare_Beneficiary_(QMB)_and_Specified_Low-Income_Medicare_Beneficiary_(SLMB)_Application_Form.doc130.14 KBMay 27 2020
- Qualified_Medicare_Beneficiary_(QMB)_and_Specified_Low-Income_Medicare_Beneficiary_(SLMB)_Application_Form.pdf283.67 KBMay 27 2020
- 9705-DHS-QMB-SLMB-MSP-Application-Revised-August-2021.pdf
- 5 Fillable LTC Application and Redetermination Forms
- DHS FIA 9709 LTC Application FINAL 7-17.pdf215.29 KBMay 27 2020
- DHS FIA 9709R LTC Redet Application FINAL R 7-17.pdf138.31 KBMay 27 2020
- DHS FIA 9709 LTC Application FINAL 7-17.pdf
- 6 FSP Program Reporting Guide
- FSP Program Reporting Guide-Eng 12-12.pdf42.2 KBMay 27 2020
- FSP Program Reporting Guide-Eng 12-12.pdf
- DHS-FIA 247 Multi-Purpose Earnings Verification Form
- DHS.FIA-247-Multi-Purpose-Earnings-Verification-Form.pdf66.74 KBMay 27 2020
- DHS.FIA-247-Multi-Purpose-Earnings-Verification-Form.pdf
- DHS-FIA 500 Medical Report Form
- 0500-B Verification of Activity Participation Form.pdf113.22 KBMay 27 2020
- DHR_FIA_500-Medical-Report-Form-revised-August-2018-1.pdf33.31 KBMay 27 2020
- 0500-B Verification of Activity Participation Form.pdf
- DHS-FIA 604-A School Attendance Verification
- DHS.FIA-604A-School-Attendance-Revised-7-17-3.pdf17.57 KBMay 27 2020
- DHS.FIA-604A-School-Attendance-Revised-7-17-3.pdf
- DHS-FIA 1131 Primary Prevention Initiative Health Care Form
- DHS_FIA_1131-PPI-form.pdf58.38 KBMay 27 2020
- DHS_FIA_1131-PPI-form.pdf
- 0007-Employment-Verification-Form.pdf124.63 KBSeptember 27 2024
- 0009-Dependent-Care-Verification-Form.pdf55.62 KBSeptember 27 2024
- 0010-Insurance-Verification-Form.pdf49.29 KBSeptember 27 2024
- 0011-Bank-Verification-Form.pdf50.46 KBSeptember 27 2024
- DHS_FIA_1151 Funeral Directors form.pdf18.04 KBMay 27 2020
- 1 FIA Change Report Form
- To-Apply-for-Assistance
- 1--Read-FIA-Fact-Sheet
- Facts-You-Should-Know.doc23 KBMay 27 2020
- Facts-You-Should-Know.pdf55.37 KBMay 27 2020
- Facts-You-Should-Know.doc
- 2--Fill-Out-App-for-Assistance
- 9701-DHS-FIA-Application-for-Assistance-7.18.2024.pdf482.3 KBSeptember 10 2024
- 9702-DHS-Application-for-One-Person-Revised-April-2023-English-1.pdf417.45 KBApril 24 2023
- 9704-DHS-APPLICATION FOR EMERGENCY ASSISTANCE 8.2023.doc142 KBSeptember 01 2023
- 9707 DHS Rights and Responsibilities revised 03-2023 English.pdf236.8 KBApril 26 2023
- 9708-A-Application-FC-Subsidized-Adopt.APRIL-26.pdf253.56 KBMay 25 2021
- 9711 E- ESAP Simplified Application Revised April 2023 English.pdf362.74 KBApril 26 2023
- 9711-Req-Assist-Revised-3.2023.docx90.99 KBJuly 31 2023
- 9701-DHS-FIA-Application-for-Assistance-7.18.2024.pdf
- 3-Sign--Rights-and-Responsibilities
- 9707 DHS Rights and Responsibilities revised 03-2023.pdf236.8 KBApril 26 2023
- 9707 DHS Rights and Responsibilities revised 03-2023.pdf
- 1--Read-FIA-Fact-Sheet
- 1179 - EBT Fraud Attestation Form.pdf188.84 KBMarch 24 2023
- OHEP
- Farsi
- To Apply for Assistance
- DHS_FIA_9711Req-Assist Revised 3-2023_Farsi No highlights (1).pdf653.51 KBApril 24 2023
- DHS_FIA_9711Req-Assist Revised 3-2023_Farsi No highlights (1).pdf
- To Apply for Assistance
- French
- To Apply for Assistance
- DHS_FIA_9711A Req-Assist Revised 3-2023_French No hightlights (1).pdf309.92 KBApril 24 2023
- DHS_FIA_9711A Req-Assist Revised 3-2023_French No hightlights (1).pdf
- To Apply for Assistance
- Korean
- To Apply for Assistance
- DHS_FIA_ 9711A Req-Assist Revised 3-2023_Korean No highlights.pdf614.82 KBApril 24 2023
- DHS_FIA_ 9711A Req-Assist Revised 3-2023_Korean No highlights.pdf
- To Apply for Assistance
- Nepalese
- To Apply for Assistance
- DHS_FIA_9711A Req-Assist Revised 3-2023_Nepali No highlights.pdf1.19 MBApril 24 2023
- DHS_FIA_9711A Req-Assist Revised 3-2023_Nepali No highlights.pdf
- To Apply for Assistance
- Russian
- Other-Forms
- Request-for-Hearing-Form--Russian.doc44.5 KBFebruary 14 2020
- Request-for-Hearing-Form--Russian.pdf132.63 KBFebruary 14 2020
- Request-for-Hearing-Form--Russian.doc
- To-Apply-for-Assistance
- 1-Read--FIA-Fact-Sheet-FIA
- Facts-You-Should-Know--Russian.doc37 KBFebruary 14 2020
- Facts-You-Should-Know--Russian.pdf106.31 KBFebruary 14 2020
- Facts-You-Should-Know--Russian.doc
- 2-Fill-Out--Application-for-Assistance
- Application-for-Assistance--Russian.doc229 KBFebruary 14 2020
- Application-for-Assistance--Russian.pdf197.01 KBFebruary 14 2020
- Application-for-Assistance--Russian.doc
- 3-Sign--Rights-and-Responsibilities
- Your-Rights-and-Responsibilities--Russian.doc111 KBFebruary 14 2020
- Your-Rights-and-Responsibilities--Russian.pdf211.71 KBFebruary 14 2020
- Your-Rights-and-Responsibilities--Russian.doc
- 9711A DHS FIA Russian Revised 3-2023.pdf473.15 KBApril 26 2023
- 1-Read--FIA-Fact-Sheet-FIA
- Other-Forms
- Spanish
- OHEP
- DHS-FIA-807-OHEP-Household-Worksheet - Spanish.pdf205.29 KBOctober 03 2024
- DHS-FIA-809-OHEP-Landlord-Agreement - Spanish.pdf264.26 KBOctober 03 2024
- Income Verification of Self-Employment_Sp.pdf205.18 KBNovember 19 2020
- OHEP2025Application - Spanish Fillable.pdf0.93 MBOctober 21 2024
- DHS-FIA-807-OHEP-Household-Worksheet - Spanish.pdf
- Para-Solicitar-Asistencia
- 1--Lea-la-hoja-de-datos-de-FIA
- Datos-Importantes-Que-Uested-Debe-Saber.doc24.5 KBMay 27 2020
- Datos-Importantes-Que-Uested-Debe-Saber.pdf53.7 KBMay 27 2020
- Datos-Importantes-Que-Uested-Debe-Saber.doc
- 2--Llene-una-solicitud-para-asistencia-para-los-programs-de
- La-Solicitud-Para-La-Asistencia.doc294.5 KBMay 27 2020
- La-Solicitud-Para-La-Asistencia.pdf341.52 KBMay 27 2020
- La-Solicitud-Para-La-Asistencia.doc
- 3--Firme-derechos-y-responsabilidades
- Derechos-Y-Responsabilidades.doc67.5 KBMay 27 2020
- Derechos-Y-Responsabilidades.pdf65.16 KBMay 27 2020
- Derechos-Y-Responsabilidades.doc
- Other-Forms
- FSP-Program-Reporting-Guide
- FSP Reporting Guide_Spanish 5-14.pdf37.92 KBMay 27 2020
- FSP Reporting Guide_Spanish 5-14.pdf
- Mo-Pedir-Una-Audiencia-Si-Piesa-Que-Nos-Hemos-Equivocado.doc39.5 KBMay 27 2020
- Mo-Pedir-Una-Audiencia-Si-Piesa-Que-Nos-Hemos-Equivocado.pdf24.15 KBMay 27 2020
- FSP-Program-Reporting-Guide
- 9711a REQUEST FOR ASSISTANCE FORM Spanish.doc86.5 KBMay 27 2020
- 1--Lea-la-hoja-de-datos-de-FIA
- 1179 - EBT Fraud Attestation Form - Spanish.pdf181.23 KBMarch 24 2023
- 9701-DHS-FIA-Application-for-Assistance-Revised-7-2024_Spanish-Rev-7.16.24.pdf485.91 KBSeptember 10 2024
- 9702-DHS-Application-for-One-Person-Revised-April-2023_Spanish-2.pdf405.16 KBApril 24 2023
- 9704-DHS-FIA-–-Aplicacion-para-Asistencia-de-Emergencia-Revisada-8-2023-.docx69.12 KBSeptember 01 2023
- 9705sp-DHS-QMB-SLMB-MSP-Application-August-2021.pdf257.18 KBAugust 09 2021
- 9707 DHS Rights and Responsibilities revised 03-2023 Spanish.pdf254.36 KBApril 26 2023
- 9708-A-Application-FC-Subsidized-Adopt.APRIL-26_Spanish.pdf284.93 KBMay 25 2021
- 9711-E-ESAP-Simplified Application Revised April 2023 (Spanish).pdf387.95 KBApril 26 2023
- DHS-FIA-9780-OHEP-Application-Spanish-1.pdf411.61 KBSeptember 23 2024
- DHS-FIA 247 MULTI-PURPOSE EARNINGS VERIFICATION FORM SPANISH.pdf89.69 KBMay 25 2022
- DHS FIA - 334 Request For Fair Hearing SP - Fillable.pdf106.03 KBOctober 12 2023
- DHS_FIA_491 Change Report form 2.2020.pdf120.74 KBMay 27 2020
- DHS_FIA_500-Medical-Report-Form-revised-August-2018-Spanish-1.docx35.83 KBMay 27 2020
- DHS_FIA_1130-Verf-Rent-Living-Arr-Spanish-2.doc77 KBMay 27 2020
- DHS_FIA_9711A-Req-Assist Revised 3-2023 Spanish.pdf356.89 KBApril 28 2023
- OHEP-Folleto-FY-2021-1.pdf648.87 KBJune 12 2020
- OHEP
- TIG
- To Apply for Assistance
- 9711A DHS FIA Tigre Revised 3-2023.pdf334.76 KBApril 26 2023
- 9711A DHS FIA Tigre Revised 3-2023.pdf
- To Apply for Assistance
- Traditional Chinese
- To Apply for Assistance
- DHS_FIA_9711 9711A Req-Assist Revised 3-2023_Chinese_Traditional No highlights (1).pdf762.04 KBApril 24 2023
- DHS_FIA_9711 9711A Req-Assist Revised 3-2023_Chinese_Traditional No highlights (1).pdf
- To Apply for Assistance
- Vietnamese
- To Apply for Assistance
- DHS_FIA_9711A Req-Assist Revised 3-2023_Vietnamese No highlights (1).pdf2.12 MBApril 24 2023
- DHS_FIA_9711A Req-Assist Revised 3-2023_Vietnamese No highlights (1).pdf
- To Apply for Assistance
- Amharic
- Other
- SUN Bucks Fair Hearing Request Form 2024.pdf110.83 KBJune 12 2024
- SUN Bucks Fair Hearing Request Form 2024.pdf
- SSA Forms
- Pediatric Symptom Checklist.pdf134.02 KBSeptember 09 2024
- Pediatric Symptom Checklist.pdf