Forms and Applications
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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 of Disaster Lost During D-SNAP Only(HS-3023) (Available May 8, 2023 - May 12, 2023)
- Spanish - Affidavit of Disaster Lost During D-SNAP Only
- 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
- SNAP Medical Deduction Information
- 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 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 (Vietnamese) (HS-02984V)
- Personal Safety Curriculum Notification for Drop-in Centers (HS-2994) - Instructions
- Personal Safety Curriculum Notification for Drop-in Centers (Spanish) (HS-2994SP) - Instructions
- 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)
- 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)
- 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
- 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)
- hs-3130 Abuse Reporting Log - instructions
- hs-3109 SSBG Change in Circumstances - instructions
- hs-3115 SSBG Service Proposal - 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-3467 Adult Protective Services Sub-Recipient Invoice
- hs-3470 Specific Assistance to Individuals Only - instructions
- hs-3475 SSBG Authorized Signatories - instructions
- hs-3476 SSBG Social Assessment and Service Plan - instructions
- hs-3479 SSBG Monthly Services Report Form - instructions
- hs-3480 SSBG Missed Appointment Log - instructions
- hs-3488 SSBG Client Waiting List - Instructions
- hs-3489 SSBG Refusal Of Service - Instructions