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Administrative Operations
- DGS Emergency Release Request Form 2015_11_18.pdf
  24.44 KB
  February 14 2020
- DGS Emergency Release Request Form Instructions 2015_11_18.pdf
  58.65 KB
  February 14 2020
CSEA Forms
- AutorizaciÃ³n de depÃ³sito directo de ManutenciÃ³n de Menores - 10.28.14.pdf
  66.91 KB
  February 14 2020
- CSEA-Application-Form-980-980A.pdf
  417.91 KB
  February 14 2020
- Direct Deposit Application Update - 06.30.16.docx
  24.38 KB
  February 14 2020
- Direct Deposit Application Update - Spanish - 06.30.16.docx
  44.53 KB
  February 14 2020
- Financial-Statement-DR30.pdf
  82.22 KB
  February 14 2020
- Motion for Modification ccdr006.pdf
  67.82 KB
  February 14 2020
- New-Application-Form-980-980A-rev5-Rev-Spanish.pdf
  611.65 KB
  February 14 2020
FIA Forms
- Amharic
  - To Apply for Assistance
    - 9711-A Amharic REQUEST FOR ASSISTANCE FORM.doc
      103.5 KB
      February 14 2020
- Arabic
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Arabic.doc
      93.5 KB
      February 14 2020
- Burmese
  - To Apply for Assistance
    - 911a REQUEST FOR ASSISTANCE FORM Burmese.doc
      61.5 KB
      February 14 2020
- Chinese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Chinese.doc
      61 KB
      February 14 2020
- English
  - OHEP
    - Alimony-Child Support Form.pdf
      47.23 KB
      February 14 2020
    - Concern-for-Personal-Safety-Privacy-Form-1.pdf
      53.83 KB
      February 14 2020
    - Crisis Season Declaration Form.pdf
      138.3 KB
      February 14 2020
    - Declaration of Zero Income Form.pdf
      39.63 KB
      February 14 2020
    - Household Worksheet.pdf
      46.17 KB
      February 14 2020
    - Income Verification of Self-Employment.pdf
      56.48 KB
      February 14 2020
    - Instructions for Completing Your Application.pdf
      158.3 KB
      February 14 2020
    - Landlord-Agreement_0618.pdf
      59.15 KB
      February 14 2020
    - myDHR Fax Cover Sheet.pdf
      478.8 KB
      February 14 2020
    - OHEP2021-Application-English.pdf
      313.3 KB
      June 12 2020
    - OHEP_2021-Instructions-English.pdf
      169.71 KB
      June 12 2020
    - Physician Certification Form.pdf
      52.58 KB
      February 14 2020
    - Proxy Authorization Form.pdf
      43.72 KB
      February 14 2020
    - Rent - Living Arrangements Form.pdf
      55.08 KB
      February 14 2020
    - Resource Provider Statement.pdf
      41.86 KB
      February 14 2020
    - Wage Form.pdf
      99.55 KB
      February 14 2020
  - Other-Forms
    - 1 FIA Change Report Form
      - DHS_FIA_491 Change Report form.pdf
        104.73 KB
        February 14 2020
    - 2 Request for Information to Verify Eligibility
      - DHS_FIA_1052 Req Verify7-2017.pdf
        30.7 KB
        February 14 2020
    - 3 Request Appeal for Hearing
      - DHS_FIA_334 Request For Fair Hearing.doc
        43 KB
        February 14 2020
      - DHS_FIA_334 Request For Fair Hearing.pdf
        33.63 KB
        February 14 2020
    - 4 QMB and SLMB Programs
      - 9705-DHS-QMB-SLMB-MSP-Application-Revised-6-12-18.doc
        129.5 KB
        February 14 2020
      - Qualified_Medicare_Beneficiary_(QMB)_and_Specified_Low-Income_Medicare_Beneficiary_(SLMB)_Application_Form.doc
        130.14 KB
        February 14 2020
      - Qualified_Medicare_Beneficiary_(QMB)_and_Specified_Low-Income_Medicare_Beneficiary_(SLMB)_Application_Form.pdf
        283.67 KB
        February 14 2020
    - 5 Fillable LTC Application and Redetermination Forms
      - DHS FIA 9709 LTC Application FINAL 7-17.pdf
        215.29 KB
        February 14 2020
      - DHS FIA 9709R LTC Redet Application FINAL R 7-17.pdf
        138.31 KB
        February 14 2020
    - 6 FSP Program Reporting Guide
      - FSP Program Reporting Guide-Eng 12-12.pdf
        42.2 KB
        February 14 2020
    - DHS-FIA 247 Multi-Purpose Earnings Verification Form
      - DHS.FIA-247-Multi-Purpose-Earnings-Verification-Form.pdf
        66.74 KB
        February 14 2020
    - DHS-FIA 500 Medical Report Form
      - DHR_FIA_500-Medical-Report-Form-revised-August-2018-1.pdf
        33.31 KB
        February 14 2020
    - DHS-FIA 604-A School Attendance Verification
      - DHS.FIA-604A-School-Attendance-Revised-7-17-3.pdf
        17.57 KB
        February 14 2020
    - DHS-FIA 1131 Primary Prevention Initiative Health Care Form
      - DHS_FIA_1131-PPI-form.pdf
        58.38 KB
        February 14 2020
    - DHS_FIA_1151 Funeral Directors form.pdf
      18.04 KB
      February 14 2020
  - To-Apply-for-Assistance
    - 1--Read-FIA-Fact-Sheet
      - Facts-You-Should-Know.doc
        23 KB
        February 14 2020
      - Facts-You-Should-Know.pdf
        55.37 KB
        February 14 2020
    - 2--Fill-Out-App-for-Assistance
      - 9701-DHS-FIA-CARES-Application-for-Assistance-Revised-07-2018-2-1.pdf
        273.43 KB
        February 14 2020
      - 9701-DHS-FIA-CARES-Application-for-Assistance Revised 2.2020 FINAL.pdf
        271 KB
        June 04 2020
      - 9702 Application for one person Final 3-21-2017.pdf
        214.25 KB
        February 14 2020
      - DHR_FIA_CARES_9707 Rights and Responsibilities revised 9.4.2014.pdf
        176.69 KB
        February 14 2020
      - DHR_FIA_CARES_9711 Revised 9-9-14.pdf
        392.56 KB
        February 14 2020
    - 3-Sign--Rights-and-Responsibilities
      - 9707 DHS Rights and Responsibilities Revised 7-17 .doc
        105.5 KB
        February 14 2020
      - 9707-DHS-Rights-and-Responsibilities-Revised-7-17.pdf
        114.5 KB
        February 14 2020
- Farsi
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Farsi.doc
      80.5 KB
      February 14 2020
- French
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM French.doc
      87.5 KB
      February 14 2020
- Korean
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM KOREAN.doc
      62.5 KB
      February 14 2020
- Nepalese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM NEP.doc
      68 KB
      February 14 2020
- Russian
  - Other-Forms
    - Request-for-Hearing-Form--Russian.doc
      44.5 KB
      February 14 2020
    - Request-for-Hearing-Form--Russian.pdf
      132.63 KB
      February 14 2020
  - To-Apply-for-Assistance
    - 1-Read--FIA-Fact-Sheet-FIA
      - Facts-You-Should-Know--Russian.doc
        37 KB
        February 14 2020
      - Facts-You-Should-Know--Russian.pdf
        106.31 KB
        February 14 2020
    - 2-Fill-Out--Application-for-Assistance
      - Application-for-Assistance--Russian.doc
        229 KB
        February 14 2020
      - Application-for-Assistance--Russian.pdf
        197.01 KB
        February 14 2020
    - 3-Sign--Rights-and-Responsibilities
      - Your-Rights-and-Responsibilities--Russian.doc
        111 KB
        February 14 2020
      - Your-Rights-and-Responsibilities--Russian.pdf
        211.71 KB
        February 14 2020
    - 9711a REQUEST FOR ASSISTANCE FORM Russian.doc
      69 KB
      February 14 2020
- Spanish
  - OHEP
    - OHEP-2021-Application-Spanish.pdf
      298.64 KB
      June 15 2020
    - OHEP-2021-Instructions-Spanish.pdf
      73.96 KB
      June 15 2020
    - OHEP-Folleto-FY-2021-1.pdf
      648.87 KB
      June 12 2020
  - Other-Forms
    - FSP-Program-Reporting-Guide
      - FSP Reporting Guide_Spanish 5-14.pdf
        37.92 KB
        February 14 2020
    - DHR_FIA_334-Request-For-Hearing-Spanish-8.2019-1.doc
      37 KB
      February 14 2020
    - DHR_FIA_334-Request-For-Hearing-Spanish-8.2019-1.pdf
      37.4 KB
      February 14 2020
    - Mo-Pedir-Una-Audiencia-Si-Piesa-Que-Nos-Hemos-Equivocado.doc
      39.5 KB
      February 14 2020
    - Mo-Pedir-Una-Audiencia-Si-Piesa-Que-Nos-Hemos-Equivocado.pdf
      24.15 KB
      February 14 2020
  - Para-Solicitar-Asistencia
    - 1--Lea-la-hoja-de-datos-de-FIA
      - Datos-Importantes-Que-Uested-Debe-Saber.doc
        24.5 KB
        February 14 2020
      - Datos-Importantes-Que-Uested-Debe-Saber.pdf
        53.7 KB
        February 14 2020
    - 2--Llene-una-solicitud-para-asistencia-para-los-programs-de
      - La-Solicitud-Para-La-Asistencia.doc
        294.5 KB
        February 14 2020
      - La-Solicitud-Para-La-Asistencia.pdf
        341.52 KB
        February 14 2020
    - 3--Firme-derechos-y-responsabilidades
      - Derechos-Y-Responsabilidades.doc
        67.5 KB
        February 14 2020
      - Derechos-Y-Responsabilidades.pdf
        65.16 KB
        February 14 2020
    - 9711a REQUEST FOR ASSISTANCE FORM Spanish.doc
      86.5 KB
      February 14 2020
  - 9701-DHS_FIA_CARES_SPA.pdf
    586.58 KB
    February 14 2020
  - DHS_FIA_491-Change-Report-form-Spanish.pdf
    91.31 KB
    February 14 2020
  - DHS_FIA_500-Medical-Report-Form-revised-August-2018-Spanish-1.docx
    35.83 KB
    February 14 2020
  - DHS_FIA_1130-Verf-Rent-Living-Arr-Spanish-2.doc
    77 KB
    February 14 2020
- TIG
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Tig.doc
      70.5 KB
      February 14 2020
- Traditional Chinese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Traditional Chinese.doc
      67.5 KB
      February 14 2020
- Vietnamese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Vietnamese.doc
      104.5 KB
      February 14 2020

DHS General Information

Report Child
Abuse or Neglect

311 West Saratoga Street, Baltimore, MD 21201

1-800-332-6347 | TTY 1-800-735-2258

© 2020 Maryland.gov

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