Get Wa Dshs 10-410 2018-2026

The WA DSHS 10-410 form, also known as the adult family home license application, is essential for individuals or entities seeking to operate an adult family home in Washington State. This guide provides step-by-step instructions to help you efficiently complete the application online.

Follow the steps to fill out the WA DSHS 10-410 online.

1. Press the ‘Get Form’ button to access the WA DSHS 10-410 form and open it in your preferred editor.
2. In Section 1, specify the type of application you are submitting by selecting either 'Initial,' 'Change of Ownership,' or 'Relocation.' Ensure you include the required application fee and your current adult family home (AFH) address and license number.
3. Complete Section 2 by providing the name, street address, and contact details of the proposed adult family home. If your mailing address differs from the street address, include it here.
4. Enter landlord information in Section 3. If the landlord is not the sole proprietor, indicate whether they will take an active interest in the operation of the adult family home.
5. In Section 4, provide your Unified Business Identifier (UBI) number and Federal Employer Identification Number (EIN) if applicable.
6. If your business structure is a corporation, partnership, or LLC, complete Section 5 with the legal name of your entity, contact numbers, and mailing address.
7. Section 6 requires listing all individuals affiliated with the entity, including their titles, social security numbers, dates of birth, and percentage of ownership.
8. In Section 7, fill in the name of the sole proprietor or entity representative and their name as it appears on their birth certificate.
9. Provide information regarding your spouse or state registered domestic partner in Section 8, if applicable, including their name as it appears on the birth certificate.
10. Section 9 requires the name of the resident manager, including their name as it appears on their birth certificate.
11. In Section 10, indicate your intent regarding the admission and care of residents with specific needs, checking the applicable box.
12. Fill out Section 11 regarding any past licensing, contracting, or certification history, making sure to provide details if you answer 'Yes' to any questions.
13. Complete Section 12 by obtaining and submitting an online background authorization form for relevant individuals involved with the adult family home.
14. Answer questions regarding current employment with state agencies in Section 13 and list any individuals employed in Section 14.
15. In Section 15, certify the accuracy of your application and provide signatures where required, ensuring that you meet all the certification statements.
16. Finally, review all sections for completeness and accuracy. Save your changes, then download, print, or share the completed WA DSHS 10-410 form as needed.

Complete your WA DSHS 10-410 application online today to ensure your adult family home meets all necessary licensing requirements.