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Get the free DSHS Form 10-417 "Adult Family Home Caregiver ...

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AGING AND LONGER SUPPORT ADMINISTRATION (ALTA)Adult Family Home Caregiving Experience Attestation (CEA) Why must this CEA form be completed? Washington state law (RCW 70.128.120) specifies the minimum
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Start by downloading the DSHS Form 10-417 "Adult" from the official DSHS website.
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Anyone who meets the eligibility criteria and needs to apply for assistance or services as an adult through DSHS may need to fill out the DSHS Form 10-417 "Adult". This could include individuals seeking medical assistance, long-term care services, food assistance, cash assistance, or other programs provided by DSHS.
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DSHS Form 10-417, known as the 'adult' form, is a document used by the Washington State Department of Social and Health Services (DSHS) for reporting information related to adults receiving services or assistance.
Individuals who are applying for or receiving adult services from DSHS are required to file DSHS Form 10-417.
To fill out DSHS Form 10-417, individuals should follow the instructions provided on the form, ensuring that all required fields are completed accurately with personal information and details pertaining to the services received.
The purpose of DSHS Form 10-417 is to collect necessary information to assess eligibility for services and to maintain accurate records for individuals receiving assistance from the department.
Individuals must report personal information such as name, address, date of birth, and details of the services being requested or received, as well as any relevant financial information.
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