Forms and Applications
Family Assistance Application
Apply for Families First and/or SNAP online
Tennessee Department of Human Services Application/Review of Eligibility For Families First, Supplemental Nutrition Assistance Program (SNAP):
English Application (HS-0169) - English Addendum - English Instructions - English Instructions Addendum
Spanish Application (HS-0169) - Spanish Addendum - Spanish Instructions - Spanish Instructions Addendum
Arabic Application and Addendum (HS-0169) - Arabic Instructions - Arabic Addendum-instructions
Somali Application and Addendum (HS-0169) - Somali Instructions - Somali Addendum-instructions
Verification Checklist (HS-2772) - Instructions
Verification Checklist in Spanish (HS-2771sp) - Instructions
Affidavit Request for SNAP Replacement Due to Power Outage (HS-3003) - Instructions
Affidavit Request for SNAP Replacement Due to Power Outage (HS-3003) Spanish - Instructions
Change Report (English) (HS-2302) - Instructions
Change Report (Spanish) (HS-2302sp) - Instructions
Change Report (Arabic) (HS-2302a) - Instructions
Change Report (Somali) HS-2302s) - 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
Family Assistance Self-Employment Calendar - Instructions
Family Assistance Fax Cover Sheet (English) (HS-3457) - Instructions
Family Assistance Fax Cover Sheet (Spanish) (HS-3457sp) - Instructions
Family Assistance Fax Cover Sheet (Arabic) (HS-3457a) - Instructions
Family Assistance Fax Cover Sheet (Somali) (HS-3457s) - Instructions
ADULT PROTECTIVE SERVICES
APS Confidentiality and Nondisclosure Agreement Letter
Request for Removal from Abuse Registry
hs-3468 APS Confidentiality and Nondisclosure Agreement Letter
APPEAL FORM
Civil Rights Complaint
English / Spanish / Arabic / Somali
Civil Rights Complaint Appeal
English / Spanish / Arabic / Somali
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
Application to Renew a License To Operate A Child Care Agency (HS-2012) - Instructions
Application to Renew a License To Operate A Child Care Agency (Spanish) (HS-2012SP) - Instructions
Criminal Background Check Transfer (HS-3299) - Instructions
Personal Safety Curriculum Notification (HS-2984) - Instructions
Personal Safety Curriculum Notification (Spanish) (HS-2984SP) - 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 Licensing Requirements For Child Care Agencies English
Summary of Licensing Requirements For Child Care Agencies Spanish
Influenza Information Notification Form
Child Care Fingerprint Applicant Information & Criminal/Juvenile History Disclosure Form
Transmittal Authorization Form (Open with Chrome or Internet Explorer)
Sample Professional Development Plan
Application for Child Care Payment Assistance/ SMART STEPS (HS-3408) - Instructions
Application for Child Care Payment Assistance /SMART STEPS(Spanish) (HS-3408sp) - Instructions
Application for Child Care Payment Assistance/ SMART STEPS (Arabic) (HS-3408a) - Instructions
Application for Child Care Payment Assistance/ SMART STEPS (Somali) (HS-3408s) - Instructions
Residency Questionnaire for Families Experiencing Homelessness (HS-3351) - Instructions
Residency Questionnaire for Families Experiencing Homelessness (Arabic) (HS-3351a) - Instructions
Residency Questionnaire for Families Experiencing Homelessness (Somali) (HS-3351s) - Instructions
Residency Questionnaire for Families Experiencing Homelessness (Spanish) (HS-3351sp) - Instructions
Self Employment Reporting and Verification
Child Care Emergency Preparedness Plan Checklist and Template (HS-3275)
CHILD SUPPORT FORMS
Child Support Appeal Form
Child Support Online Application
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)
Appeal From FInding (Arabic)
Appeal From Finding (Somali)
COMMUNITY SERVICES
Infant Meal Menu/Meal Count Record for 0 through 6 months (HS-3295) - Instructions
Infant Meal Menu/Meal Count Record for 6 through 11 months (HS-3296) - Instructions
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
COMMUNITY SERVICES BLOCK GRANT
COMMUNITY SERVICES BLOCK GRANT APPLICATION
RELEASE OF INFORMATION FORMS
HIPAA Authorization for Release of Medical/Health Information (HS-2557) - Instructions
HIPAA Authorization for Release of Medical/Health Information (Arabic) (HS-2557a) - Instructions
HIPAA Authorization for Release of Medical/Health Information (Somali) (HS-2557s) - Instructions
HIPAA Authorization for Release of Medical/Health Information (Spanish) (HS-2557sp) - Instructions
HIPAA Authorization for Release of Medical/Health Information (Large Print) (HS-2557LP) - Instructions
HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (HS-2939) - Instructions
HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Arabic) (HS-2939a) - Instructions
HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Somali) (HS-2939s) - Instructions
HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Spanish) (HS-2939sp) - Instructions
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)
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)
PUBLIC RECORDS REQUESTS
SOCIAL SERVICES BLOCK GRANT (SSBG)
hs-3130 Abuse Reporting Log - instructions
hs-3109 SSBG Change in Circumstances - instructions
hs-3115 SSBG Service Proposal - instructions
hs-3116 SSBG Social Assesment and Service Plan - instructions
hs-3117 Application for Social Services Block Grant (SSBG) Services - instructions
hs-3131 SSBG Annual Program Evaluation - instructions
hs-3134 SSBG Risk Factor Matrix (APS Assessment) - instructions
hs-3456 Specific Assistance Request - instructions
hs-3463 SSBG Budget Revision Form - instructions
hs-3460 SSBG Corrective Action Plan - instructions
hs-3465 SSBG Invoice for Reimbursement - instructions
hs-3470 Specific Assistance to Individuals Only - instructions
hs-3475 SSBG Authorized Signatories - instructions
hs-3476 SSBG SSBG Social Assessment and Service Plan - instructions
hs-3480 SSBG Missed Appointment Log - instructions
hs-SSBG Monthly Services Report Form - instructions
SUMMER FOOD SERVICE PROGRAM
HS-3071 Claim for Reimbursement
Summer Food Service Program Income Excess Funds
VOCATIONAL REHABILITATION FORMS
Career Counseling and Information and Referral Services Verification (HS-3289) - Instructions
FLSA Section 14c Subminimum Wage Employee Referral (HS-3287) - Instructions
Pre-Employment Transitions Services Permission (HS-3288) - Instructions