An official website of the U.S. Department of Homeland Security. DSHS PHONE NUMBER : DSHS FAX NUMBER . CREST Participant Authorization, Consolidated Appeal Request (HS-3058)- Instructions Complaint Form. 188 0 obj <>/Filter/FlateDecode/ID[<586470AFBA8F064CB53287A88ABA53D4>]/Index[168 37]/Info 167 0 R/Length 98/Prev 128726/Root 169 0 R/Size 205/Type/XRef/W[1 2 1]>>stream hs-3115 SSBG Service Proposal- instructions WebPlease complete Section I and have your employer complete Section II. "4!=A9Ek#I(8t As"k$4k$}Fbe>os];5k}B.yA57 ?0wac5 aBe} 6Za 4CMKCz-P7";{O$'cqx SE(Q&TxU|6C6If#3i{/U{_?H_+(9b}9~k6+l(Y rkv:lZG>w:l\EV{mM2FI{Qku"{<8{=rG-z:7K@Y`vgovv],_ivJ=6_Ek M hs-3470Specific Assistance to Individuals Only - instructions DHS Operational Components offer a fuller selection of online forms to the public: Federal Emergency Management Administration; Federal Emergency WebBFA Form 756 Employment Verification | New Hampshire Department of Health and Human Services page for more information. Verification of an income decrease may be requested, but not required, if it could reduce the familys copayment. Death Certificate. Citizenship and Immigration Services. hs-3476 SSBG Social Assessment and Service Plan - instructions WebSNAP provides monthly benefits that help low-income households buy the food they need. WebRegulations require us to verify income for all applicants/recipients. WebForm H1028, Employment Verification Instructions for Opening a Form Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on Raleigh, NC 27699-2001 DHS Operational Components offer a fuller selection of online forms to the public: An official website of the U.S. Department of Homeland Security. An authorized COMPANY REPRESENTATIVE (not the employee) must complete this form. DSHS, PO BOX 11699, TACOMA WA 98411-9905 . SNAP/TANF Online Application. Below that, the employee must provide their signature, date the signing, and print their name. Once complete, the employer should return the form to the requestor only (not the employee). endstream endobj startxref HIPAA Authorization for Release of Medical/Health Information (Spanish) (HS-2557sp) - Instructions Step 8 The employer must continue by entering their name or company name followed by the business address (street, city, State), phone number, and email address. 2022 Electronic Forms LLC. State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. WebSNAP & TANF Forms. by Name/Number - in the "Form" field enter all or part of the form name or number. Family Assistance Fax Cover Sheet (Arabic) (HS-3457a) - Instructions ?q)TKQ>X$*|J&" DHS SSA Protocol and Procedures for Resuming In-Person Visits Between Parents and Personal Safety Curriculum Notification for Drop-in Centers (Spanish) (HS-2994SP) - Instructions, HS-3069 Claim for Reimbursement Child and Adult Care Food Program Northeast Region (570-963-4371 or Child Support Appeal Form Spanish NC Department of Health and Human Services WebIncome Verification of Self-Employment.pdf. hs-3468APS Confidentiality and Nondisclosure Agreement Letter " #D>+!pMB AC1qb Child Support Application Please enable scripts and reload this page. 56.48 KB. Finally, employers may be required to participate in E-Verify as a result of a legal ruling. Please complete the section(s) that Nursing Facility Reporting of Omnibus Budget Reconciliation Act (OBRA) Information, Consent For Voluntary Inpatient Treatment, Explanation of Voluntary Admission Rights, Solicitud Para Examen De Emergencia Y Tratamiento Involuntarios, Application for Involuntary Emergency Examination & Treatment, Explanation of Rights Under Involuntary Emergency Treatment (302), Solicitud Para Extension Del Tratamiento Involuntario, Notice of Intent to File a Petition for Extended Involuntary Treatment and Explantion of Rights (303), Ley De Procedimientos De Salud Mental De 1976, Notice with Intent to File a Petition for Extendied Involuntary Treatment and Explanation of Rights (304b or 305), Notice of Hearing on Petition for Involuntary Treatment and Explanation of Rights (304c), Solicitud De Tratamiento No Voluntario a Traves Del Sistema Penal, Petition for Involuntary Treatment Via the Criminal Justice System, Peticon De Envio a Tratamiento Involuntario Despues De Fallo De Incapacidad Para Ser Sometido A Juicio Cuando No Hay Incapacidad Mental Grave, Petition for Commitment for Involuntary Treatment After Finding of Incompetency to Stand Trial Where Severe Mental Disability is Not Present, Transfer of Involuntary Committed Persons from Inpatient to Outpatient Status, Notice of a Hearing on Petition to Transfer for Involuntary Treatment and Explanation of Rights, Petition to Transfer for Persons in Involuntary Treatment, Estate Recovery Program Questions and Answers, DHS Application Lifecycle Management (ALM) Baseline (Infrastructure) v27, 2014 Bureau of Autism Services Family and Individual Mini-Grants, Adult Protective Services (APS) and Mandatory Reporting Webinar Opportunities, August 28, 2019 Third Party Liability Recovery, Business Intelligence Required Deliverables, Business Partner Network Connectivity STD-ENSS022, CERTIFICADO DE ANTECEDENTES DE ABUSO DE MENORES DE PENSILVANIA, Certified Recovery Specialists in Centers of Excellence MA Bulletin, Child Care Services / Program Employee or Contractor Fingerprinting, Children's Mental Health Matters #58 Oct 2018, Commonwealth of PA TIBCO Managed File Transfer (MFT) System, Commonwealth Record Management STD-DMS012, CONSENT / RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION, COTS, Transfer Technologies and Emerging Technology Evaluation & Selection, December 28, 2018 Third Party Liability Recovery, Disbursement and Corresponding Dates for Cash / SNAP Benefits Jan / Feb 2019, DISBURSEMENT AND CORRESPONDING DATES FOR CASH / SNAP BENEFITS JANUARY AND FEBRUARY 2019, el formulario PA 600B Programa de Tratamiento y Prevencin contra, Electronic Records Managemnt in Database Management Systems, ELRC Directors and Quality Leads Touch Point Call with Program Quality Assessment Team October 26, 2018, ELRC Directors and Quality Leads Touch Point Call with Program Quality Assessment Team, ELRC Transition Q & A Document Updated 11.01.2018, Employee >=14 Years Contact w / Children Fingerprinting, Family Child Care Home Provider Fingerprinting, February 19, 2019 Third Party Liability Recovery, February 25, 2019 Third Party Liability Recovery, Fiscal Year 2017-18 Social Services Block Grant Post-Expenditure Report, Form PA 600B Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program, Human Services Development Fund Summary for Fiscal Year Ending June 30, 2017, Impact of Supervision on Personal Care Home Staff A Free Training for Personal Care Home Administrators, Individual >=18 Years in Family Living, Community or Host Home Fingerprinting, Individual >=18 Years in Foster Home Fingerprinting, Individual >=18 Years in Licensed Child Care Home Fingerprinting, Individual >=18 Years in Prospective Adoptive Home Fingerprinting, INSTRUCCIONES SOBRE EL FORMULARIO DE SOLICITUD DE AUDIENCIA IMPARCIAL, June 12, 2019 Third Party Liability Recovery, Managed Care Operations Memorandum General Operations MCOPS Memo # 02 / 2019-002, Managed Care Operations Memorandum General Operations MCOPS Memo # 07 / 2019-010, March 27, 2019 Third Party Liability Recovery, Maximum Rate of State Participation for Employee Benefits for County Children and Youth Agencies and Mental Health / Intellectual Disabilities / Early Intervention Programs, MS SQL Server 2012 / 2014 Naming and Coding Standard, November 20, 2018 Third Party Liability Recovery, November 27, 2018 Third Party Liability Recovery, OLTL Service Authorization Form HCBS Waiver Programs, Office of Mental Health and Substance Abuse. HIPAA Authorization for Release of Medical/Health Information (Large Print) (HS-2557LP) - Instructions Webunder the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. However, employers with federal contracts or subcontracts that contain the Federal Acquisition Regulation (FAR) E-Verify clause are required to enroll in E-Verify as a condition of federal contracting. hs-3109 SSBG Change in Circumstances- instructions hs-3456 Specific Assistance Request- instructions Step 1 Download the wage verification form in eitherAdobe PDF, Microsoft Word (.docx), or Open Document Text (.odt) format. AUTHORITY: 1939 PA 280 as amended (MCL 400.8, MCL English/Spanish/ Arabic / Somali, Adult Day Care Criminal/Juvenile History & State Registry Review Disclosure (HS-2680) - Instructions Family Assistance Fax Cover Sheet (Spanish) (HS-3457sp) - Instructions 58.39 KB. hVmo8+adCKph DMK-/L)=$0CFBK 919-855-4850, Section V-(a) Human Resources - Division of Health Benefits, Section VII Procurement and Contract Services, Special Assistance Administrative Letters, Special Assistance In Home Program Admin Letters, Special Assistance In Home Program Change Notices, Special Assistance In Home Case Management Manual, Subsidized Child Care Reimbursement System, Subsidized Child Care Reimbursement System Administrative Letters, Subsidized Child Care Reimbursement System Change Notice, Mental Health, Developmental Disabilities and Substance Abuse Services, EIS-4000 CODES APPENDIX TABLE OF CONTENTS, EIS-4000 CODES APPENDIX B - MEDICAID CODES, EIS-4000 CODES APPENDIX E - TRANSITIONAL CODES, Independent Living Older Blind Policies and Procedures Manual, Independent Living Services Program Manual, Vocational Rehabilitation Policies and Procedures Manual, Services for the Deaf and Hard of Hearing, Formulaires en Franais - Forms in French, Cov ntaub ntawv nyob rau hauv Hmong - Forms in Hmong, Cc biu mu bng ting Vit - Forms in Vietnamese, Enterprise Program Integrity Control System (EPICS), Food Stamp Information System (FSIS) Users, Performance Management/Reporting & Evaluation, https://policies.ncdhhs.gov/divisional/social-services/forms/dss-8113-wage-verification-form, How To Navigate DHHS Policies and Manuals. |B@,g`b9,|M]I; ys9L\p'00~] W-||s_kB?b^@s@+m":3XIx10m|,{x!#|O^lpqq WebDEPARTMENT OF HEALTH AND HUMAN SERVICES PO BOX 2992MH OMAHA, NE 68103-2992 Employer Name: Employer Address: EARNED INCOME VERIFICATION REQUEST Fax Number: (402)595-1901 Please sign this form and have your employer complete the information. You are required by law to complete and return Secure .gov websites use HTTPS Keystone State. Child Welfare Services. SNAP E&T Skills2Work Application. WebThe form must be mailed directly to the Child Care Information Services (CCIS) agency. Facebook page for Georgia Department of Human Services, Twitter page for Georgia Department of Human Services, Linkedin page for Georgia Department of Human Services, Instagram page for Georgia Department of Human Services, YouTube page for Georgia Department of Human Services, District Youth Development Coordinators Contact List, Applying for Child Support as a Kinship Caregiver, Community-Based Support for Kinship Caregivers. 168 0 obj <> endobj hs-3463 SSBG Budget Revision Form - instructions HS-3083 Claim for Reimbursement Child and Adult Care Food Program (Homes Only) Appeal From Finding The document must be filled in by the employer providing information related to the employees work schedule, hours worked per week (on average), hourly rate ($/HR) or salary, and any bonuses or tips earned. English/Spanish/ Arabic / Somali Somali Application and Addendum (HS-0169)-Somali Instructions-Somali Addendum-instructions, Verification Checklist (HS-2772) - Instructions Change Report (Spanish) (HS-2302sp) - Instructions Parent/Guardian Authorization For The Tennessee Department Of Education Or Local Education Agency To Release School Attendance Records- (Spanish) Consolidated Appeal Request in Arabic (HS-3058A) An official website of the United States government. HIPAA Authorization for Release of Medical/Health Information (Arabic) (HS-2557a) - Instructions Criminal History Check. WebEmployment Verification . Infant Meal Menu/Meal Count Record for 6 through 11 months (HS-3296) - Instructions hs-3131 SSBG Annual Program Evaluation - instructions Secure .gov websites use HTTPS This is a very important form because your benefits depend on returning this form within ten (10) days. Summer Food Service Program (SFSP) and Child and Adult Care Food Program (CACFP) Bond Waiver Request (HS-3267) - Instructions, COMMUNITY SERVICES BLOCK GRANT APPLICATION, HIPAA Authorization for Release of Medical/Health Information (HS-2557) - Instructions AffidavitRequest for SNAP Replacement Due to Power Outage (HS-3003) Spanish- Instructions, Change Report (English) (HS-2302) - Instructions J-1 Visa. VOCATIONAL REHABILITATION FORMS. WebWe must have an accurate record of your employees work schedule and employment income. Section I: To be completed by customer . Webinformation will not be given even with authorization. Divorce Record. E-Verify employers verify the Appeal From FInding (Arabic) Local, state, and federal government websites often end in .gov. Arabic Application and Addendum (HS-0169)-Arabic Instructions-Arabic Addendum-instructions E-Verify employers verify the identity and employment eligibility of newly hired employees by electronically matching information given by employees on the Form I-9, Employment Eligibility Verification, against records available to the Social Security Administration (SSA) and the Department of Homeland Security (DHS). Spanish Application(HS-0169)-Spanish Addendum-Spanish Instructions-Spanish Instructions Addendum endstream endobj 169 0 obj <>/Metadata 10 0 R/Pages 166 0 R/StructTreeRoot 20 0 R/Type/Catalog/ViewerPreferences<>>> endobj 170 0 obj <>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/StructParents 0/Tabs/S/TrimBox[0.0 0.0 792.0 612.0]/Type/Page>> endobj 171 0 obj <>stream Immunization Record. HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Spanish) (HS-2939sp) - Instructions +MpsP5:z|*_^V+we(zmBcNdGrml&\.^*/&%)Jv%xdxOW 2D3LU&kEB" e! H\n0E/Se. Report Fraud & Abuse. Filter Results By Office of Admin CCIS Office of Administration Office of Child Development and Early Learning Office of Children Youth and Families Licensing & Providers. Learn About Law Enforcement Training Opportunities, Provide Feedback or Make Complaints to DHS, This page was not helpful because the content, Application to Replace Permanent Resident Card, DHS Traveler Redress Inquiry Program (DHS TRIP), Passport Application Forms, U.S. Department of State, Automated Clearinghouse Credit Enrollment, Declaration for Free Entry of Unaccompanied Articles, Certificate of Registration for Personal Effects Taken Abroad, National Emergency Training Center General Admissions Application, National Emergency Training Center General Admissions Short Form Application, Federal Emergency Management Administration, Federal Emergency Management Administration (Flood hazard), U.S. By using the website, you agree to our use of cookies to analyze website traffic and improve your experience on our website. hs-3460 SSBG Corrective Action Plan - instructions E-Verify is a web-based system that allows enrolled employers to confirm the eligibility of their employees to work in the United States. Central Region (717) 772-7078 or (800) 222-2117. endstream endobj 172 0 obj <>stream WebSummer Food Service Program Income Excess Funds. K WebDepartment of Human Services > Find a Document > For Providers > Child Care Forms. aBzw.^"LGK7JU5(;Hwu jT725z\AC%O`BOO. Step 6 Regarding the employees work schedule, the employer must detail the employees working hours by entering the start time (From) and finish time (To) for each day of the week the employee works. 2001 Mail Service Center 888-338-7410: Please use blue or black ink and print or type. Application for Child Care Payment Assistance/SMART STEPS(Somali)(HS-3408s) - Instructions, Residency Questionnaire for Families Experiencing Homelessness (HS-3351) - Instructions Supplemental Nutrition Assistance Program (SNAP), Deaf, Deaf-Blind and Hard of Hearing Services, Community Tennessee Rehabilitation Centers, Family Assistance Live Chat, Direct Email, Child Care Payment Assistance Online Application, Arabic Application and Addendum (HS-0169), Somali Application and Addendum (HS-0169), Verification Checklist in Spanish (HS-2771sp), AffidavitRequest for SNAP Replacement Due to Power Outage (HS-3003), AffidavitRequest for SNAP Replacement Due to Power Outage (HS-3003) Spanish, Families First Program Waiver of Hearing and Disqualification Consent Agreement (HS-3113), Families First Program Waiver of Hearing and Disqualification Consent Agreement (Spanish) (HS-3113SP), Family Assistance Self-Employment Calendar, Family Assistance Fax Cover Sheet (English) (HS-3457), Family Assistance Fax Cover Sheet (Spanish) (HS-3457sp), Family Assistance Fax Cover Sheet (Arabic) (HS-3457a), Family Assistance Fax Cover Sheet (Somali) (HS-3457s), hs-3468APS Confidentiality and Nondisclosure Agreement Letter, Consolidated Appeal Request in Spanish (HS-3058SP), Consolidated Appeal Request in Arabic (HS-3058A), Consolidated Appeal Request in Somali (HS-3058S), Withdrawal of Appeal for Fair Hearing(HS-2908), Adult Day Care Criminal/Juvenile History & State Registry Review Disclosure (HS-2680), Application to Renew a License To Operate A Child Care Agency (HS-2012), Application to Renew a License To Operate A Child Care Agency (Spanish) (HS-2012SP), Criminal Background Check Transfer (HS-3299), Personal Safety Curriculum Notification (HS-2984), Personal Safety Curriculum Notification(Spanish) (HS-2984SP), Personal Safety Curriculum Notification (Vietnamese) (HS-02984V), Personal Safety Curriculum Notification for Drop-in Centers (HS-2994), Personal Safety Curriculum Notification for Drop-in Centers (Spanish) (HS-2994SP), HS-3069 Claim for Reimbursement Child and Adult Care Food Program, HS-3083 Claim for Reimbursement Child and Adult Care Food Program (Homes Only), Instructions Monthly Racial and Ethnic Data, Child Care Fingerprint Applicant Information & Criminal/Juvenile History Disclosure Form, Application for Child Care Payment Assistance/SMART STEPS (HS-3408), Application for Child Care Payment Assistance /SMART STEPS(Spanish) (HS-3408sp), Application for Child Care Payment Assistance/SMART STEPS (Arabic) (HS-3408a), Application for Child Care Payment Assistance/SMART STEPS(Somali)(HS-3408s), Residency Questionnaire for Families Experiencing Homelessness (HS-3351), Residency Questionnaire for Families Experiencing Homelessness (Arabic)(HS-3351a), Residency Questionnaire for Families Experiencing Homelessness (Somali)(HS-3351s), Residency Questionnaire for Families Experiencing Homelessness (Spanish)(HS-3351sp), Complaint Under Civil Rights Act of 1964 (Arabic), Complaint Under Civil Rights Act of 1964 (Somali), Complaint Under Civil Rights Act of 1964 (Spanish), Withdrawal of Civil Rights Complaint (Arabic), Withdrawal of Civil Rights Complaint (Somali), Withdrawal of Civil Rights Complaint (Spanish), Infant Meal Menu/Meal Count Record for 0 through 6 months (HS-3295), Infant Meal Menu/Meal Count Record for 6 through 11 months (HS-3296), Public Release for Summer Food Service Program Open Sites (HS-3266), Summer Food Service Program (SFSP) and Child and Adult Care Food Program (CACFP) Bond Waiver Request (HS-3267), HIPAA Authorization for Release of Medical/Health Information (HS-2557), HIPAA Authorization for Release of Medical/Health Information (Arabic) (HS-2557a), HIPAA Authorization for Release of Medical/Health Information (Somali) (HS-2557s), HIPAA Authorization for Release of Medical/Health Information (Spanish) (HS-2557sp), HIPAA Authorization for Release of Medical/Health Information (Large Print) (HS-2557LP), HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (HS-2939), HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Arabic) (HS-2939a), HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Somali) (HS-2939s), HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Spanish) (HS-2939sp), Parent/Guardian Authorization For The Tennessee Department Of Education Or Local Education Agency To Release School Attendance Records, Parent/Guardian Authorization For The Tennessee Department Of Education Or Local Education Agency To Release School Attendance Records- (Spanish), General Authorization for Release of Information to the TDHS to a 3rd Party, General Authorization for Release of Information to the TDHS to a 3rd Party- (Spanish), General Authorization For Release Of Information To The Tennessee Department Of Human Services, General Authorization For Release Of Information To The Tennessee Department Of Human Services- (Spanish), hs-3117 Application for Social Services Block Grant (SSBG) Services, hs-3134 SSBGRisk Factor Matrix (APS Assessment), hs-3467 Adult Protective Services Sub-Recipient Invoice, hs-3470Specific Assistance to Individuals Only, hs-3476 SSBG Social Assessment and Service Plan, hs-3479 SSBG Monthly Services Report Form, SummerFoodServiceProgramIncomeExcess Funds, Career Counseling and Information and Referral Services Verification (HS-3289), FLSA Section 14c Subminimum Wage Employee Referral (HS-3287), Pre-Employment Transitions Services Permission (HS-3288). Consolidated Appeal Request in Somali (HS-3058S), Withdrawal of Appeal for Fair Hearing(HS-2908) -Form Instructions, Civil Rights Complaint WebDepartment of Human Services Employment and Income Verification IL444-4831 (N-10-10) Page 1 of 1 Issued by: Date: Permission Statement I authorize my employer to release Energy Programs. Proudly founded in 1681 as a place of tolerance and freedom. ?:R* LDc"X=Hv*d3:hVq|uauBP}RiY1:e)(uhml1mWdnWsR5FY&6>,%$YaE^Z*) 6%RH93 0oQHHm| You may be trying to access this site from a secured browser on the server. General Authorization for Release of Information to the TDHS to a 3rd Party- (Spanish) Appeal From Finding (Spanish) Withdrawal of Civil Rights Complaint (Arabic) Complaint Under Civil Rights Act of 1964 (Somali) The .gov means its official. 919-855-4800, Division of Budget and Analysis Application for Child Care Payment Assistance /SMART STEPS(Spanish) (HS-3408sp)-Instructions Official websites use .gov Step 1 Download the wage verification form in either Adobe PDF, Microsoft Word (.docx), or Open Document Text (.odt) format. Return or fax the completed form to the address or fax number or https:// means youve safely connected to the .gov website. WebWe are requesting verification of wages for the above-named employee. WebWage Verification Form (dss-8113) Department of Health and Human Services Home US North Carolina Agencies Department of Health and Human Services Wage Verification Form This government document is issued by Department of Health and Human Services for use in North Carolina Download Form Add to Favorites File Details: PDF Downloads: The case is automatically referred for further verification. Civil Rights Complaint Appeal hs-3488 SSBG Client Waiting List - Instructions Step 2 The requesting party must begin filling in the form by entering their name, phone number, email address, and fax number. hs-3134 SSBGRisk Factor Matrix (APS Assessment) - instructions Transmittal Authorization Form(Open with Chrome or Internet Explorer) DSS-8113: Wage Verification Form. hs-3467 Adult Protective Services Sub-Recipient Invoice If the hours vary, the employer must explain the variance. 0 hs-3117 Application for Social Services Block Grant (SSBG) Services- instructions Form 809 (Rev. Send completed form to OHR via fax to 501-682-6553, via e-mail emp.verifications@dhs.arkansas.gov or via mail to OHR Recruitment; PO Box 1437, SLOT W301, Little Rock, AR 72201-1437 I am a: Current Employee Format of response: Form Formal Letter Method of delivery: E-mail Fax $7X;*H$ 2w k${b$[> >N HH3012Y? Children's Health Insurance. WebForms - Related Links. Application for Child Care Payment Assistance/SMART STEPS (Arabic) (HS-3408a) - Instructions Step 9 To complete the form, the employer must provide their signature and business title before dating the document and printing their name. September 30 2020. Official websites use .gov %PDF-1.6 % Public Release for Summer Food Service Program Open Sites (HS-3266) - Instructions Child Care Fingerprint Applicant Information & Criminal/Juvenile History Disclosure Form I, _____, authorize _____ to (name of customer) release information to the Pre-Employment Transitions Services Permission (HS-3288) - Instructions. hbbd``b` FLSA Section 14c Subminimum Wage Employee Referral (HS-3287) - Instructions Residency Questionnaire for Families Experiencing Homelessness (Arabic)(HS-3351a) - Instructions Po BOX 11699, TACOMA WA 98411-9905 TACOMA WA 98411-9905 '' LGK7JU5 ;. '' field enter all or part of the address O ` BOO part of the address of employees... State, and federal government websites often end in.gov to complete and return Secure.gov use... Decrease may be requested, but not required, if it could the! To the Child Care Information Services ( CCIS ) agency 2001 Mail Center! 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