Forms and Applications

FAMILY ASSISTANCE

Family Assistance Application

Apply for Families First and/or SNAP online

Tennessee Department of Human Services Application/Review of Eligibility For Families First, Food Stamps:  
English Application (HS-0169) - English AddendumEnglish Instructions - English Instructions Addendum
Spanish Application (HS-2775) - Spanish Addendum - Spanish Instructions - Spanish Instructions Addendum
Arabic Application and Addendum (HS-0169) - Arabic Instructions
Somali Application and Addendum (HS-0169) - Somali Instructions

Verification Checklist (HS-2772) - Instructions
Verification Checklist in Spanish (HS-2771) - Instructions

Request for Food Stamp Replacements Due to Household Misfortune (HS-3003) - Instructions

Change Report (English) (HS-2302) - Instructions
Change Report (Arabic) (HS-2302a) - Instructions
Change Report (Somali) (HS-2302s) - Instructions
Change Report (Spanish) (HS2302sp) - Instructions

Families First Program Waiver of Hearing and Disqualification Consent Agreement (HS-3113) - Instructions
Families First Program Waiver of Hearing and Disqualification Consent Agreement (Spanish) (HS-3113SP) - Spanish Instructions

APPEAL FORM

Civil Rights Complaint
English Spanish
Civil Rights Complaint Appeal
English Spanish

Consolidated Appeal Request (HS-3058) - Instructions
Consolidated Appeal Request in Spanish (HS-3058SP) - Spanish Instructions

Withdrawal of Appeal for Fair Hearing (HS-2908) Form Instructions

CHILD AND ADULT CARE LICENSING

Adult Day Care Criminal/Juvenile History & State Registry Review Disclosure (HS-2680) - Instructions
Personal Safety Curriculum Notification for Drop-in Centers (HS-2994) - Instructions
Personal Safety Curriculum Notification for Drop-in Centers (Spanish) (HS-2994SP) - Instructions

CHILD CARE AND ADULT CARE FOOD PROGRAM

HS-3069 Claim for Reimbursement Child and Adult Care Food Program
​HS-3083 Claim for Reimbursement Child and Adult Care Food Program (Homes Only)
HS-3191 Monthly Racial and Ethnic Data
Instructions Monthly Racial and Ethnic Data

CHILD CARE SERVICES

Home TN-ELDS Documentation Form
Center TN-ELDS Documentation Form

Summary of Family Home Licensing Requirements
Summary of Group Home Licensing Requirements
Summary of Center Licensing Requirements
Personal Safety Notification Form
Sample Influenza Information Notification Form
Child Care Fingerprint Applicant Information & Criminal/Juvenile History Disclosure Form
Transmittal Authorization Form
Sample Professional Development Plan

Application for SMART STEPS Child Care Payment Assistance (HS-3036) - Instructions
Application for SMART STEPS Child Care Payment Assistance (Spanish)  (HS-3036) - Instructions

Registration Agreement for Child Care Agencies-Professionals Processing EAV's Online (HS-3281) - Instructions

CHILD SUPPORT FORMS

Child Support Appeal Form
Child Support Application
Child Support Application Spanish
Client Complaint

CIVIL RIGHTS FORMS

Complaint Under Civil Rights Act of 1964
Complaint Under Civil Rights Act of 1964 (Arabic)
Complaint Under Civil Rights Act of 1964 (Somali)
Complaint Under Civil Rights Act of 1964 (Spanish)
Withdrawal of Civil Rights Complaint
Withdrawal of Civil Rights Complaint (Arabic)
Withdrawal of Civil Rights Complaint (Somali)
Withdrawal of Civil Rights Complaint (Spanish)
Appeal From Finding
Appeal From Finding (Spanish)

COMMUNITY SERVICES

Public Release for Summer Food Service Program Open Sites (HS-3266) - Instructions
Summer Food Service Program (SFSP) and Child and Adult Care Food Program (CACFP) Bond Waiver Request (HS-3267) - Instructions

CUSTOMER SERVICE FORMS

Customer Feedback Form

EXTERNAL DATA REQUESTS

External Data Requests

HIPAA RELEASE FORMS

HIPAA Authorization for Release of Information
HIPAA Authorization for Release of Information - (Spanish)
Parent/Guardian Authorization For The Tennessee Department Of Education Or Local Education Agency To Release School Attendance Records
Parent/Guardian Authorization For The Tennessee Department Of Education Or Local Education Agency To Release School Attendance Records - (Spanish)
General Authorization for Release of Information to the TDHS to a 3rd Party
General Authorization for Release of Information to the TDHS to a 3rd Party - (Spanish)
Tennessee Department Of Human Services HIPAA Authorization For Release Of Medical/Health Information To 3rd Party
Tennessee Department Of Human Services HIPAA Authorization For Release Of Medical/Health Information To 3rd Party - (Spanish)
General Authorization For Release Of Information To The Tennessee Department Of Human Services
General Authorization For Release Of Information To The Tennessee Department Of Human Services - (Spanish)

MEDICAL EVALUATION UNIT

Referral to the Tennessee Alliance for Legal Services (TALS) (HS-2959) - Instructions

PUBLIC RECORDS REQUESTS

Public Records Policy

Summer Food Service Program

HS-3071 Claim for Reimbursement
Summer Food Service Program Income Excess Funds

VOCATIONAL REHABILITATION FORMS

VR Appeal Form
Career Counseling and Information and Referral Services Verification (HS-3289) - Instructions
FLSA Section 14c Subminimum Wage Employee Referral (HS-3287) - Instructions