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How to use or fill out DHS 2128 ENG with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by reading the Notice of Privacy Practices and Notice of Rights and Responsibilities on Attachment A. Tear off these pages for your records.
- Fill in your personal information in Section 1, including your name, address, date of birth, and phone number. Ensure accuracy as this information is crucial for processing.
- Indicate whether you are currently in a long-term care facility and provide the necessary details if applicable.
- Complete questions regarding your financial situation, including cash on hand, bank accounts, assets, and income sources. Use additional sheets if needed.
- Sign and date the form at the designated section. You can do this electronically within our platform for convenience.
- Attach any required proofs as copies (not originals) and submit the completed form to your county or tribal agency promptly.
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