WA DSHS 10-410 2018 free printable template
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Adult Family Home License Application
Review the Resource / Instructions document when completing this application.
Section 1. Type of Application
Initial (application fee $2750)
Change of Ownership
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How to fill out WA DSHS 10-410
How to fill out WA DSHS 10-410
01
Obtain the WA DSHS 10-410 form from the Washington State Department of Social and Health Services website or local office.
02
Fill in your personal information, including your name, address, phone number, and date of birth.
03
Provide details about your household members, including their names, relationship to you, and date of birth.
04
Indicate your income sources and amounts, including any wages, benefits, or other earnings.
05
Specify your expenses, such as rent, utilities, and childcare costs, to give a clear picture of your financial situation.
06
If applicable, fill out any additional sections related to your specific situation (e.g., medical expenses or special circumstances).
07
Review the completed form for accuracy and ensure all required signatures are provided.
08
Submit the form either online, by mail, or in person to your local DSHS office.
Who needs WA DSHS 10-410?
01
Individuals and families who are applying for or receiving assistance from the Washington State Department of Social and Health Services.
02
Those seeking eligibility for programs such as food assistance, cash assistance, or medical assistance.
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What is WA DSHS 10-410?
WA DSHS 10-410 is a form used by the Washington State Department of Social and Health Services for reporting financial information related to individuals applying for or receiving public assistance.
Who is required to file WA DSHS 10-410?
Individuals applying for or currently receiving certain public assistance benefits in Washington State are required to file WA DSHS 10-410.
How to fill out WA DSHS 10-410?
To fill out WA DSHS 10-410, individuals need to provide personal information, including income details, household information, and any relevant financial data as instructed on the form.
What is the purpose of WA DSHS 10-410?
The purpose of WA DSHS 10-410 is to collect detailed financial data to determine eligibility for public assistance programs and to ensure compliance with state regulations.
What information must be reported on WA DSHS 10-410?
The information that must be reported on WA DSHS 10-410 includes income sources, amounts, household size, expenses, and any other financial details relevant to the assessment of public assistance eligibility.
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