Forms

HHS forms are used every day to perform tasks such as applying for benefits, contracting to provide goods or services, reporting incidents, declaring end of life wishes, and conducting other business.

ES = Spanish version available.

Title
Form H1172, EBT Card, PIN and Data Entry Request ES
Form H1111, Card Order Discrepancy Verification
Form H4861, Receipt of Notice ES
Form H4857, Notice of Decision, Administrative Disqualification Hearing
Form H4856, Request for Another Appointment for Administrative Disqualification Hearing
Form H4855, Statement of Household Member's Rights in Administrative Disqualification Hearing ES
Form H4851-C, Notice of Administrative Disqualification Hearing
Form H4833, Appeals Information ES
Form H4806, Request for Another Appointment — Request to Withdraw
Form H4800-ADH, Request for Administrative Disqualification Hearing
Form 3470, Request for Advance or Reimbursement (RAR) Centers for Independent Living Base/Operation Grant
Form 3455, Provider Staff Information
Form 3160, Quarterly Program Performance Report
Form 3155, Base or Operational Grant Budget Revision Request
Form 3153, Purchased Services Contract Monthly Complaint and Inquiries Report