Forms
Loading
Search
- 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 - Spanish 02-04-22.docx34.94 KBFebruary 07 2022
- 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
- 9711-A Amharic REQUEST FOR ASSISTANCE FORM.doc103.5 KBFebruary 14 2020
- 9711-A Amharic REQUEST FOR ASSISTANCE FORM.doc
- To Apply for Assistance
- Arabic
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM Arabic.doc93.5 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM Arabic.doc
- To Apply for Assistance
- Burmese
- To Apply for Assistance
- 911a REQUEST FOR ASSISTANCE FORM Burmese.doc61.5 KBFebruary 14 2020
- 911a REQUEST FOR ASSISTANCE FORM Burmese.doc
- To Apply for Assistance
- Chinese
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM Chinese.doc61 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM Chinese.doc
- To Apply for Assistance
- English
- OHEP
- Alimony-Child Support Form.pdf47.23 KBMay 27 2020
- Concern-for-Personal-Safety-Privacy-Form-1.pdf53.83 KBMay 27 2020
- Crisis Season Declaration Form.pdf138.3 KBMay 27 2020
- Declaration of Zero Income Form.pdf39.63 KBMay 27 2020
- Household Worksheet.pdf46.17 KBMay 27 2020
- Income Verification of Self-Employment.pdf56.48 KBMay 27 2020
- Instructions for Completing Your Application.pdf158.3 KBMay 27 2020
- Landlord-Agreement-FY23.pdf688.96 KBJuly 29 2022
- myDHR Fax Cover Sheet.pdf478.8 KBMay 27 2020
- OHEP_-Application_2023_EN_Fillable.pdf552.54 KBJuly 29 2022
- Physician Certification Form.pdf52.58 KBMay 27 2020
- Proxy Authorization Form.pdf43.72 KBMay 27 2020
- Rent - Living Arrangements Form.pdf55.08 KBMay 27 2020
- Resource Provider Statement.pdf41.86 KBMay 27 2020
- Wage Form.pdf99.55 KBMay 27 2020
- Alimony-Child Support Form.pdf
- Other-Forms
- 1 FIA Change Report Form
- DHS_FIA_491 Change Report form 2.2020.pdf119.34 KBMay 27 2020
- DHS_FIA_491 Change Report form 2.2020.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
- 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-CARES-Application-for-Assistance-Revised-2.2020-FINAL-15.pdf257.76 KBSeptember 09 2020
- 9701-DHS-FIA-CARES-Application-for-Assistance Revised 2.2020 FINAL.pdf257.77 KBSeptember 09 2020
- 9702-DHS-Application-for-one-person-revised 2.2020 FINAL.pdf234.43 KBMay 27 2020
- 9704-DHS-application-for-emergency-assistance-revision-5.21-3.pdf219.57 KBMay 25 2021
- 9707 DHS Rights and Responsibilities revised March 2020. final.pdf343.95 KBMay 27 2020
- 9708-A-Application-FC-Subsidized-Adopt.APRIL-26.pdf253.56 KBMay 25 2021
- 9711-E-ESAP-Simplified-Application-Revised-April-2021-edits-1-1.pdf323.59 KBApril 29 2021
- DHS_FIA_CARES_9711-Req-Assist-5.4.21.-edits-doc-1.pdf307.32 KBMay 04 2021
- 9701-DHS-FIA-CARES-Application-for-Assistance-Revised-2.2020-FINAL-15.pdf
- 3-Sign--Rights-and-Responsibilities
- 9707 DHS Rights and Responsibilities revised March 2020. final.doc166 KBMay 27 2020
- 9707 DHS Rights and Responsibilities revised March 2020. final.pdf343.95 KBMay 27 2020
- 9707 DHS Rights and Responsibilities revised March 2020. final.doc
- 1--Read-FIA-Fact-Sheet
- OHEP
- Farsi
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM Farsi.doc80.5 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM Farsi.doc
- To Apply for Assistance
- French
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM French.doc87.5 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM French.doc
- To Apply for Assistance
- Korean
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM KOREAN.doc62.5 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM KOREAN.doc
- To Apply for Assistance
- Nepalese
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM NEP.doc68 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM NEP.doc
- 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 REQUEST FOR ASSISTANCE FORM Russian.doc69 KBFebruary 14 2020
- 1-Read--FIA-Fact-Sheet-FIA
- Other-Forms
- Spanish
- OHEP
- Income Verification of Self-Employment_Sp.pdf205.18 KBNovember 19 2020
- OHEP-2019-Application-Spanish-1.pdf298.93 KBMay 27 2020
- OHEP-2019-Instructions-Spanish.pdf73.71 KBMay 27 2020
- OHEP-2021-Application-and-Instructions-Spanish.pdf407.03 KBSeptember 30 2020
- OHEP-2021-ApplicationInstructions-Spanish.pdf72.08 KBNovember 20 2020
- OHEP 2018 Application- Spanish.pdf288.21 KBMay 27 2020
- OHEP 2018 Instructions- Spanish.pdf122.76 KBMay 27 2020
- OHEP2019Application_Spanish_IS_FINAL.pdf300.56 KBMay 27 2020
- OHEP_-Application_2023_SP_Fillable.pdf455.21 KBJuly 29 2022
- OHEP_2019Checklist_Spanish_IS_FINAL.pdf70.72 KBMay 27 2020
- Income Verification of Self-Employment_Sp.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
- DHS_FIA_334-sp-Request-For-Fair-Hearing-April-28-SP-fillable.pdf106.03 KBApril 29 2021
- 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
- 9701-DHS-FIA-CARES-Application-for-Assistance Revised 2.2020 FINAL_ES.pdf466.73 KBMay 27 2020
- 9702-DHS-Application-for-one-person-revised 2.2020 FINAL_ES.pdf382.12 KBMay 27 2020
- 9704-sp-DHS-application-for-emergency-assistance-revisions-5.2021.pdf223.49 KBMay 25 2021
- 9705sp-DHS-QMB-SLMB-MSP-Application-August-2021.pdf257.18 KBAugust 09 2021
- 9708-A-Application-FC-Subsidized-Adopt.APRIL-26_Spanish.pdf284.93 KBMay 25 2021
- 9711-E-ESAP-Simplified-Application-Revised-4.2021-FINAL_ES.spanish.Edit-docx.pdf328.52 KBApril 29 2021
- DHS-FIA 247 MULTI-PURPOSE EARNINGS VERIFICATION FORM SPANISH.pdf89.69 KBMay 25 2022
- 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
- OHEP-Folleto-FY-2021-1.pdf648.87 KBJune 12 2020
- OHEP
- TIG
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM Tig.doc70.5 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM Tig.doc
- To Apply for Assistance
- Traditional Chinese
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM Traditional Chinese.doc67.5 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM Traditional Chinese.doc
- To Apply for Assistance
- Vietnamese
- To Apply for Assistance
- 9711a REQUEST FOR ASSISTANCE FORM Vietnamese.doc104.5 KBFebruary 14 2020
- 9711a REQUEST FOR ASSISTANCE FORM Vietnamese.doc
- To Apply for Assistance
- Amharic