Dhs 1121-2026

1. Click ‘Get Form’ to open the DHS 1121 in the editor.
2. Begin by printing the full name of the Applicant/Beneficiary and check the appropriate box to either designate or revoke an authorized representative.
3. Next, print the full name of the Authorized Representative in the designated field.
4. Fill in the mailing address of the Applicant/Beneficiary, including city, state, and zip code.
5. The Applicant/Beneficiary must sign and date the form. If signing with an 'x', ensure a witness is present to sign as well.
6. Complete the section for validity by entering either a date or event that indicates how long this authorization remains effective.
7. The Authorized Representative should then provide their mailing address and telephone number, followed by their signature and date.
8. Once completed, return the original form along with any necessary documentation to your assigned eligibility worker.

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