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This version of the form is not currently in use and is provided for reference only. Download this version of
DSHS Form 10-412
for the current year.
DSHS Form 10-412 Adult Family Home License Relinquishment Letter - Washington
What Is DSHS Form 10-412?
This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form 10-412?A: Form 10-412 is the Adult Family Home License Relinquishment Letter used in Washington.
Q: What is an Adult Family Home License?A: An Adult Family Home License is a license issued to a facility that provides housing and care services to elderly or disabled individuals.
Q: When would someone need to submit Form 10-412?A: Someone would need to submit Form 10-412 if they are relinquishing their Adult Family Home License in Washington.
Q: What information is required on Form 10-412?A: Form 10-412 requires information such as the licensee's name, license number, date of relinquishment, and reasons for relinquishment.
Q: Is there a fee for submitting Form 10-412?A: No, there is no fee for submitting Form 10-412.
Q: What happens after submitting Form 10-412?A: After submitting Form 10-412, the licensing office will process the relinquishment and update the status of the Adult Family Home License.
Form Details:
- Released on May 1, 2015;
- The latest edition provided by the Washington State Department of Social and Health Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of DSHS Form 10-412 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.
