Get Wa Dshs 10-410 2020-2026

Completing the WA DSHS 10-410 Adult Family Home License Application is an essential process for individuals and entities seeking to provide care services. This guide will walk you through the necessary steps to fill out the form online, ensuring that you provide accurate and complete information.

Follow the steps to successfully complete the application.

1. Click ‘Get Form’ button to obtain the application and open it in your editor.
2. In Section 1, select the type of application you are submitting: Initial, Change of Ownership, or Relocation Only. Specify the current Adult Family Home address and license number as applicable.
3. Proceed to Section 2, where you need to provide the proposed Adult Family Home name, street address, mailing address (if different), city, state, zip code, county, facility telephone number, fax number, cell phone number, and a required email address.
4. In Section 3, answer whether the property owner(s) will take an active interest in the operation of the Adult Family Home by selecting 'Yes' or 'No.' Fill in the property owner(s) names and their physical address.
5. Section 4 requires you to provide the Federal Employer Identification Number (EIN) of the applicant.
6. If applicable, complete Section 5 with the legal entity information including the legal name, telephone number, mailing address, and the fax number.
7. In Section 6, list all individuals affiliated with the legal entity, including their names, titles or positions, social security numbers, dates of birth, and percentages of ownership.
8. Complete Section 7 with the name of the sole proprietor or entity representative.
9. If applicable, answer Section 8 regarding married couples or state-registered domestic partners applying together.
10. Provide the resident manager's name in Section 9.
11. In Section 10, indicate any specialty training you have completed relating to the care of residents with specific needs.
12. Section 11 focuses on your licensing, contracting, and certification history. Answer all questions related to past licenses and contracts.
13. In Section 12, complete the online background authorization form and submit with the confirmation code for all individuals listed.
14. Answer whether currently employed by the DSHS in Section 13 and provide any required details.
15. Sign and date Sections 14 and 15, confirming consent for release and certification of the information provided. Ensure that all required documents are included.
16. Finally, you can save your changes, download, print, or share the completed form as needed.

Complete your Adult Family Home License Application online today for a smoother processing experience.