WA DSHS 04-417 2014-2025 free printable template
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AGENCY NUMBERDIVISION OF BEHAVIORAL HEALTH AND RECOVERY (BHR)BHR Target Detox Short Form
Client Identification
1. LAST NAME2. FIRST NAME4. OTHER LAST NAME3. MIDDLE NAME
5. GENDERMale6. DATE OF BIRTHFemale8.
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How to fill out WA DSHS 04-417
How to fill out WA DSHS 04-417
01
Obtain the WA DSHS 04-417 form from the Washington State Department of Social and Health Services website or your local DSHS office.
02
Fill in your personal information in the designated sections, including your name, address, date of birth, and contact information.
03
Provide details about your household members, including their names, dates of birth, and relationships to you.
04
Indicate your current income sources and amounts, including employment, benefits, and any other financial support.
05
Complete the section regarding your housing situation, including your rent or mortgage payment and any utilities.
06
Review all information for accuracy and completeness before signing and dating the form.
07
Submit the completed form to your local DSHS office or through the specified submission method indicated on the form.
Who needs WA DSHS 04-417?
01
Individuals or families seeking public assistance benefits from the Washington State Department of Social and Health Services.
02
People applying for programs such as food assistance, medical care, or financial aid.
03
Anyone required to report changes in their financial situation or household composition to the DSHS.
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What is WA DSHS 04-417?
WA DSHS 04-417 is a form used in Washington State by the Department of Social and Health Services (DSHS) for reporting information related to child support services or other social services programs.
Who is required to file WA DSHS 04-417?
Individuals or agencies that are involved in child support enforcement, such as custodial parents, non-custodial parents, or attorneys representing either party, are required to file WA DSHS 04-417.
How to fill out WA DSHS 04-417?
To fill out WA DSHS 04-417, you should carefully read the instructions provided with the form, fill in all required fields with accurate information, and ensure that any supporting documentation is attached before submitting it to the appropriate DSHS office.
What is the purpose of WA DSHS 04-417?
The purpose of WA DSHS 04-417 is to collect necessary information to assist in the establishment, modification, or enforcement of child support orders in Washington State.
What information must be reported on WA DSHS 04-417?
The form requires reporting personal information such as names, addresses, case numbers, and details regarding the income, employment, and financial status of the parties involved in the child support case.
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