DHS 1121 Designation or Revocation of an Authorized Representative-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 designate or revoke authorization.
3. Next, print the full name of the Authorized Representative.
4. Provide the Applicant/Beneficiary's address in the designated field.
5. The Applicant/Beneficiary must sign their name and date it. If signing with an 'x', ensure a witness is present.
6. Complete the Date or Event field indicating how long the authorization is valid; leaving this blank renders it invalid.
7. The Authorized Representative should review, fill in their mailing address and phone number, then sign and date to confirm understanding of regulations.
8. Once completed, return the original and a copy to your assigned eligibility worker for processing.

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