Get Wa 10-417 2019-2026

The WA 10-417 form, also known as the Caregiving Experience Attestation, is essential for individuals applying to become licensed Adult Family Home providers in Washington State. This guide provides a clear step-by-step process to assist users in completing the form online accurately.

Follow the steps to successfully complete the WA 10-417 form.

1. Click the ‘Get Form’ button to obtain the WA 10-417 and open it in your chosen online platform.
2. In Section 1, identify yourself as either the applicant, spouse co-provider, entity representative, or resident manager by checking the appropriate box.
3. Provide your full name in the designated field as the individual applicant, co-provider, entity representative, or resident manager.
4. Fill in the name of the Adult Family Home in the specified section.
5. Enter the complete address of the proposed Adult Family Home, including city, state, and zip code.
6. Section 2 must be completed by the attestor; they should write 'N/A' for sections that do not apply to them.
7. The attestor must provide their full name and title or role in the designated fields.
8. Two contact numbers for the attestor should be recorded, ensuring to include the area code.
9. Indicate the best time for a call during weekdays, providing clear availability.
10. The attestor must describe their relationship to the individual named in Section 1 by selecting from the provided options.
11. Answer whether the individual currently works for the attestor with a simple yes or no.
12. The attestor should specify the care setting where they worked with the individual, ensuring it is licensed or contracted.
13. Provide the name of the place where the attestor and the individual worked together.
14. Confirm if the individual’s primary responsibilities included providing direct care to vulnerable adults.
15. Indicate whether the individual exceeded 1,000 hours of caregiving experience, and if no, specify the total hours.
16. The attestor must provide the dates of care provided, detailing the month and year for both starting and ending periods.
17. Answer questions regarding the individual's reliability and their ability to meet physical and emotional needs of care recipients.
18. The attestor must include their signature and the date, ensuring the signature is notarized to meet legal requirements.
19. Review all fields for completeness and accuracy before finalizing the form.
20. Once satisfied, save the changes made, download the completed form, and ensure you print or share it as necessary.

Complete your WA 10-417 form online today for efficient submission!