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Administrative Operations
- DGS Emergency Release Request Form 2015_11_18.pdf
  24.44 KB
  November 20 2015
- DGS Emergency Release Request Form Instructions 2015_11_18.pdf
  58.65 KB
  November 20 2015
CSEA Forms
- Autorización de depósito directo de Manutención de Menores - 10.28.14.pdf
  66.91 KB
  March 30 2016
- CSEA-Application-Form-980-980A.pdf
  417.91 KB
  March 21 2014
- Direct Deposit Application Update - 06.30.16.docx
  24.38 KB
  July 19 2016
- Direct Deposit Application Update - Spanish - 06.30.16.docx
  44.53 KB
  July 19 2016
- Financial-Statement-DR30.pdf
  82.22 KB
  March 21 2014
- Motion for Modification ccdr006.pdf
  67.82 KB
  March 21 2014
- New-Application-Form-980-980A-rev5-Rev-Spanish.pdf
  611.65 KB
  March 21 2014
FIA Forms
- Amharic
  - To Apply for Assistance
    - 9711-A Amharic REQUEST FOR ASSISTANCE FORM.doc
      103.5 KB
      September 03 2014
- Arabic
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Arabic.doc
      93.5 KB
      September 03 2014
- Burmese
  - To Apply for Assistance
    - 911a REQUEST FOR ASSISTANCE FORM Burmese.doc
      61.5 KB
      September 03 2014
- Chinese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Chinese.doc
      61 KB
      September 03 2014
- English
  - OHEP
    - Alimony-Child Support Form.pdf
      47.23 KB
      June 26 2017
    - Concern-for-Personal-Safety-Privacy-Form-1.pdf
      53.83 KB
      July 19 2018
    - Crisis Season Declaration Form.pdf
      138.3 KB
      November 30 2017
    - Declaration of Zero Income Form.pdf
      39.63 KB
      July 03 2017
    - Household Worksheet.pdf
      46.17 KB
      July 03 2017
    - Income Verification of Self-Employment.pdf
      56.48 KB
      July 03 2017
    - Instructions for Completing Your Application.pdf
      158.3 KB
      July 03 2017
    - Landlord-Agreement_0618.pdf
      59.15 KB
      June 18 2018
    - myDHR Fax Cover Sheet.pdf
      478.8 KB
      June 13 2016
    - OHEP2017Application.pdf
      218.91 KB
      June 30 2016
    - OHEP 2018 Application-English.pdf
      279.63 KB
      July 03 2017
    - OHEP2019Application_FinalEnglish.pdf
      293.81 KB
      June 06 2018
    - OHEP2020Application_May-2019.pdf
      313.3 KB
      June 04 2019
    - OHEP_2019_Instructions.pdf
      184.72 KB
      June 06 2018
    - OHEP_2020Checklist_May-2019.pdf
      186.57 KB
      June 04 2019
    - Physician Certification Form.pdf
      52.58 KB
      July 08 2016
    - Proxy Authorization Form.pdf
      43.72 KB
      July 03 2017
    - Rent - Living Arrangements Form.pdf
      55.08 KB
      November 30 2017
    - Resource Provider Statement.pdf
      41.86 KB
      July 03 2017
    - Wage Form.pdf
      99.55 KB
      August 02 2017
  - Other-Forms
    - 1 FIA Change Report Form
      - DHS_FIA_491 Change Report form.pdf
        104.73 KB
        August 09 2019
    - 2 Request for Information to Verify Eligibility
      - DHS_FIA_1052 Req Verify7-2017.pdf
        30.7 KB
        August 09 2019
    - 3 Request Appeal for Hearing
      - DHS_FIA_334 Request For Fair Hearing.doc
        43 KB
        August 09 2019
      - DHS_FIA_334 Request For Fair Hearing.pdf
        33.63 KB
        August 09 2019
    - 4 QMB and SLMB Programs
      - 9705-DHS-QMB-SLMB-MSP-Application-Revised-6-12-18.doc
        129.5 KB
        July 12 2018
      - Qualified_Medicare_Beneficiary_(QMB)_and_Specified_Low-Income_Medicare_Beneficiary_(SLMB)_Application_Form.doc
        130.14 KB
        November 05 2015
      - Qualified_Medicare_Beneficiary_(QMB)_and_Specified_Low-Income_Medicare_Beneficiary_(SLMB)_Application_Form.pdf
        283.67 KB
        November 05 2015
    - 5 Fillable LTC Application and Redetermination Forms
      - DHS FIA 9709 LTC Application FINAL 7-17.pdf
        215.29 KB
        August 09 2019
      - DHS FIA 9709R LTC Redet Application FINAL R 7-17.pdf
        138.31 KB
        August 09 2019
    - 6 FSP Program Reporting Guide
      - FSP Program Reporting Guide-Eng 12-12.pdf
        42.2 KB
        January 11 2013
    - DHS-FIA 247 Multi-Purpose Earnings Verification Form
      - DHS.FIA-247-Multi-Purpose-Earnings-Verification-Form.pdf
        66.74 KB
        August 14 2019
    - DHS-FIA 500 Medical Report Form
      - DHR_FIA_500-Medical-Report-Form-revised-August-2018-1.pdf
        33.31 KB
        August 14 2019
    - DHS-FIA 604-A School Attendance Verification
      - DHS.FIA-604A-School-Attendance-Revised-7-17-3.pdf
        17.57 KB
        August 14 2019
    - DHS-FIA 1131 Primary Prevention Initiative Health Care Form
      - DHS_FIA_1131-PPI-form.pdf
        58.38 KB
        August 14 2019
    - DHS_FIA_1151 Funeral Directors form.pdf
      18.04 KB
      August 09 2019
  - To-Apply-for-Assistance
    - 1--Read-FIA-Fact-Sheet
      - Facts-You-Should-Know.doc
        23 KB
        October 10 2012
      - Facts-You-Should-Know.pdf
        55.37 KB
        October 10 2012
    - 2--Fill-Out-App-for-Assistance
      - 9701-DHS-FIA-CARES-Application-for-Assistance-Revised-07-2018-2-1.pdf
        273.43 KB
        August 08 2019
      - 9702 Application for one person Final 3-21-2017.pdf
        214.25 KB
        July 20 2017
      - DHR_FIA_CARES_9707 Rights and Responsibilities revised 9.4.2014.pdf
        176.69 KB
        October 20 2014
      - DHR_FIA_CARES_9711 Revised 9-9-14.pdf
        392.56 KB
        October 20 2014
    - 3-Sign--Rights-and-Responsibilities
      - 9707 DHS Rights and Responsibilities Revised 7-17 .doc
        105.5 KB
        August 15 2019
      - 9707-DHS-Rights-and-Responsibilities-Revised-7-17.pdf
        114.5 KB
        August 14 2019
- Farsi
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Farsi.doc
      80.5 KB
      September 03 2014
- French
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM French.doc
      87.5 KB
      September 03 2014
- Korean
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM KOREAN.doc
      62.5 KB
      September 03 2014
- Nepalese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM NEP.doc
      68 KB
      September 03 2014
- Russian
  - Other-Forms
    - Request-for-Hearing-Form--Russian.doc
      44.5 KB
      October 10 2012
    - Request-for-Hearing-Form--Russian.pdf
      132.63 KB
      October 10 2012
  - To-Apply-for-Assistance
    - 1-Read--FIA-Fact-Sheet-FIA
      - Facts-You-Should-Know--Russian.doc
        37 KB
        October 10 2012
      - Facts-You-Should-Know--Russian.pdf
        106.31 KB
        October 10 2012
    - 2-Fill-Out--Application-for-Assistance
      - Application-for-Assistance--Russian.doc
        229 KB
        October 10 2012
      - Application-for-Assistance--Russian.pdf
        197.01 KB
        October 10 2012
    - 3-Sign--Rights-and-Responsibilities
      - Your-Rights-and-Responsibilities--Russian.doc
        111 KB
        October 10 2012
      - Your-Rights-and-Responsibilities--Russian.pdf
        211.71 KB
        October 10 2012
    - 9711a REQUEST FOR ASSISTANCE FORM Russian.doc
      69 KB
      September 03 2014
- Spanish
  - OHEP
    - OHEP-2019-Application-Spanish-1.pdf
      298.93 KB
      August 10 2018
    - OHEP-2019-Instructions-Spanish.pdf
      73.71 KB
      August 10 2018
    - OHEP 2018 Application- Spanish.pdf
      288.21 KB
      July 03 2017
    - OHEP 2018 Instructions- Spanish.pdf
      122.76 KB
      July 03 2017
    - OHEP2019Application_Spanish_IS_FINAL.pdf
      300.56 KB
      July 05 2018
    - OHEP_2019Checklist_Spanish_IS_FINAL.pdf
      70.72 KB
      July 05 2018
  - Other-Forms
    - FSP-Program-Reporting-Guide
      - FSP Reporting Guide_Spanish 5-14.pdf
        37.92 KB
        May 09 2014
    - DHR_FIA_334-Request-For-Hearing-Spanish-8.2019-1.doc
      37 KB
      August 14 2019
    - DHR_FIA_334-Request-For-Hearing-Spanish-8.2019-1.pdf
      37.4 KB
      August 14 2019
    - Mo-Pedir-Una-Audiencia-Si-Piesa-Que-Nos-Hemos-Equivocado.doc
      39.5 KB
      October 10 2012
    - Mo-Pedir-Una-Audiencia-Si-Piesa-Que-Nos-Hemos-Equivocado.pdf
      24.15 KB
      October 10 2012
  - Para-Solicitar-Asistencia
    - 1--Lea-la-hoja-de-datos-de-FIA
      - Datos-Importantes-Que-Uested-Debe-Saber.doc
        24.5 KB
        October 10 2012
      - Datos-Importantes-Que-Uested-Debe-Saber.pdf
        53.7 KB
        October 10 2012
    - 2--Llene-una-solicitud-para-asistencia-para-los-programs-de
      - La-Solicitud-Para-La-Asistencia.doc
        294.5 KB
        October 10 2012
      - La-Solicitud-Para-La-Asistencia.pdf
        341.52 KB
        October 10 2012
    - 3--Firme-derechos-y-responsabilidades
      - Derechos-Y-Responsabilidades.doc
        67.5 KB
        October 10 2012
      - Derechos-Y-Responsabilidades.pdf
        65.16 KB
        October 10 2012
    - 9711a REQUEST FOR ASSISTANCE FORM Spanish.doc
      86.5 KB
      September 03 2014
  - 9701-DHS_FIA_CARES_SPA.pdf
    586.58 KB
    August 13 2019
- TIG
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Tig.doc
      70.5 KB
      September 03 2014
- Traditional Chinese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Traditional Chinese.doc
      67.5 KB
      September 03 2014
- Vietnamese
  - To Apply for Assistance
    - 9711a REQUEST FOR ASSISTANCE FORM Vietnamese.doc
      104.5 KB
      September 03 2014

DHS General Information

Report Child
Abuse or Neglect

311 West Saratoga Street, Baltimore, MD 21201

1-800-332-6347 | TTY 1-800-735-2258

© 2019 Maryland.gov

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