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Caregiver attestation form 2026

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The document outlines the requirements for completing the Caregiving Experience Attestation (CEA) Form A for applicants seeking licensure to operate an Adult Family Home (AFH) in Washington state. It specifies that applicants must demonstrate at least 1,000 hours of direct caregiving experience with vulnerable adults within the past 60 months, as mandated by state law. The form must be completed by individuals involved in the AFH's daily operations and requires notarization. It also details who can attest to the caregiving experience and provides instructions for submission.

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Click ‘Get Form’ to open the caregiver attestation form in the editor.
Begin by filling out Section 1, where you will indicate your role (Individual Applicant, Spouse/SRDP Co-Provider, Entity Representative, or Resident Manager) and provide your name, the proposed adult family home's name, and its address.
In Section 2, the attestor must enter their personal information including name, title or role, and two contact numbers. Ensure that all fields are filled based on personal knowledge of the applicant's caregiving experience.
Answer questions regarding the applicant’s caregiving experience. This includes confirming if they have provided direct care to vulnerable adults and detailing their responsibilities.
Once all sections are completed, ensure that the form is signed and notarized as required before submission.

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Caregiver attestation form 2026

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