Get Wa Dshs 10-410 2014

Filling out the WA DSHS 10-410 form for an adult family home license can seem daunting, but with this guide, you will navigate each section with confidence. This guide offers clear, step-by-step instructions to ensure your application is complete and accurate.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to access the WA DSHS 10-410 form and open it in your editor.
2. Begin by filling out the information about the proposed adult family home, including the name, street address, mailing address, telephone number, and other contact details.
3. Provide property owner information. Indicate whether the applicant or entity representative owns the home, and if applicable, fill in the owner's name and address.
4. Fill out the Unified Business Identifier (UBI) Number and Federal Employer Identification Number (EIN) sections as required.
5. For applicants applying as an entity, complete the Entity section with the legal name and address.
6. Complete the Individuals Affiliated with Applicant section if applying as an entity. List all persons associated with ownership and their roles.
7. Provide information about the individual applicant or entity representative including their name, date of birth, and contact information.
8. Indicate whether the applicant has a spouse or State Registered Domestic Partner and if they will be listed on the license. Provide their information if applicable.
9. Complete the Resident Manager Information section by listing the name and relevant details of the individual designated as the resident manager.
10. Mark documentation provided to verify minimum qualifications for each individual noted in the previous sections.
11. If planning to care for residents with specific needs like dementia or developmental disabilities, check the respective box and attach the relevant specialty training certificates.
12. Complete the Previous Licensing or Contracting Experience section to document any prior experience or issues.
13. Fill out the Background Information section thoroughly and attach a completed Background Authorization form for required individuals.
14. Complete the Financial Assessment Information section and answer questions truthfully.
15. Sign the certification section, confirming the accuracy of the provided information, and include any necessary signatures from partners or co-applicants.
16. Once all sections are complete, save changes, and take the opportunity to download, print, or share the form as needed.

Start your application process today by filling out the WA DSHS 10-410 form online!