DSHS Form 12-195 Disqualification Consent Agreement - Washington (Cambodian)

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington.

The document is provided in Cambodian. 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 the Disqualification Consent Agreement form in the state of Washington.

Q: Who is the form for?
A: The form is for individuals who are applying for or receiving benefits from DSHS (Department of Social and Health Services) in Washington state, and who have been disqualified from receiving benefits due to a violation of program rules.

Q: What is the purpose of DSHS Form 12-195?
A: The purpose of the form is to provide individuals with an opportunity to voluntarily agree to a disqualification and its terms in order to continue receiving benefits from DSHS.

Q: What does the form require?
A: The form requires the individual to acknowledge the violation of program rules, agree to the disqualification, and consent to the terms and conditions outlined in the agreement.

Q: Can someone refuse to sign the form?
A: Yes, someone can refuse to sign the form. However, if they refuse to sign, their benefits may be discontinued or they may be subject to other actions by DSHS.

Q: Is this form specific to the Cambodian community?
A: No, this particular form is not specific to the Cambodian community. It is used for individuals from all backgrounds who have violated program rules and are willing to consent to a disqualification.