Cost Statement Forms

The forms below are for work services (formerly Habilitation) providers to report all revenue and expenses biennially to the Department.

The Excel forms can be downloaded and complete using Microsoft Excel spreadsheet program. For further information, please read the instructions accompanying each form.

DS 1950 – Habilitation Services Cost Statement Forms
DS 1950 (3/05) (EXCEL with formulas)
DS 1950 (3/05) (EXCEL without formulas)
DS 1966 – Request for Rate Adjustment — Occupancy Change
DS 1966 (3/05) EXCEL
DS 1967 – Request for Rate Adjustment — Staffing Change.
DS 1967 (3/05) EXCEL

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Last modified: October 29, 2019