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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 12-195
for the current year.
DSHS Form 12-195 Disqualification Consent Agreement - Washington
What Is DSHS Form 12-195?
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 DSHS Form 12-195?
A: DSHS Form 12-195 is a Disqualification Consent Agreement used in Washington.
Q: What is the purpose of DSHS Form 12-195?
A: The purpose of DSHS Form 12-195 is to document an individual's consent to a disqualification from receiving certain benefits.
Q: Who uses DSHS Form 12-195?
A: DSHS Form 12-195 is used by individuals in Washington who are subject to disqualification from receiving benefits.
Q: What is a Disqualification Consent Agreement?
A: A Disqualification Consent Agreement is a legal document that acknowledges an individual's agreement to be disqualified from receiving benefits.
Q: Are there specific eligibility criteria for disqualification?
A: Yes, specific eligibility criteria determine when an individual may be subject to disqualification.
Q: What happens if I refuse to sign the Disqualification Consent Agreement?
A: If you refuse to sign the Disqualification Consent Agreement, the consequences may include potential loss of benefits or other sanctions.
Q: Can I appeal a disqualification?
A: Yes, you can appeal a disqualification decision through the appropriate channels outlined by the Washington Department of Social and Health Services (DSHS).
Form Details:
- Released on February 1, 2017;
- The latest edition provided by the Washington State Department of Social and Health Services;
- Easy to use and ready to print;
- Available in Cambodian;
- 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 12-195 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.
