Dhs 1125 instructions-2026

1. Click ‘Get Form’ to open the DHS 1125 in the editor.
2. Begin by entering the Name of the Injured Beneficiary. Ensure you include the first name, middle initial, and last name accurately.
3. Next, indicate the Date of Accident or Incident by filling in the month, day, and year when the event occurred.
4. In the section labeled 'Dated:', specify the city and state where you are signing the form.
5. Complete 'This ____day' by writing in the day when you sign this document.
6. Fill in 'Of _____, ___' with the month and year of your signature.
7. Provide your Signature as a Witness. This is self-explanatory but must be done carefully.
8. The next field requires the Signature of Adult Beneficiary, Guardian, or Representative. Make sure it is signed by an authorized individual.
9. Indicate your Printed Name as a Witness by entering your first name, middle initial, and last name.
10. Fill in your Street Address where you reside.
11. Lastly, indicate your Title or Relationship to the injured beneficiary for clarity on your connection.

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