Free letter generator
Application for a referral to a DPS and appeal against a decision
Answer a few questions and we will produce a finished letter with the legal basis, the reasoning and a list of attachments. All that is left is to print and sign it.
The generator runs entirely in your browser. Nothing you type reaches our server, including the PESEL number and the address.
Pismo, od którego zaczyna się cała sprawa. Składasz je w MOPS lub GOPS właściwym dla miejsca zamieszkania seniora, a ośrodek na tej podstawie kieruje sprawę dalej.
Twoje pismo
Przelicza się na bieżąco. Nawiasy kwadratowe to miejsca do uzupełnienia.
Pismo generuje się po polsku, bo w takiej formie składa się je w polskim urzędzie. Zmiana języka strony nie zmienia języka pisma.
[miejscowość], [data] [imię i nazwisko wnioskodawcy] [adres zamieszkania] [nazwa ośrodka pomocy społecznej] WNIOSEK O SKIEROWANIE DO DOMU POMOCY SPOŁECZNEJ Na podstawie art. 54 ust. 1 i art. 59 ust. 1 ustawy z dnia 12 marca 2004 r. o pomocy społecznej oraz § 8 ust. 1 pkt 1 rozporządzenia Ministra Pracy i Polityki Społecznej z dnia 23 sierpnia 2012 r. w sprawie domów pomocy społecznej (Dz. U. z 2025 r. poz. 51) wnoszę o skierowanie osoby wskazanej poniżej do domu pomocy społecznej dla osób w podeszłym wieku. DANE OSOBY UBIEGAJĄCEJ SIĘ O SKIEROWANIE Imię i nazwisko: [imię i nazwisko] PESEL: [PESEL] Adres zamieszkania: [adres zamieszkania] DANE WNIOSKODAWCY Imię i nazwisko: [imię i nazwisko] Adres: [adres] Stopień pokrewieństwa: [np. córka, syn] UZASADNIENIE Osoba ubiegająca się o skierowanie wymaga opieki przez całą dobę i nie jest w stanie samodzielnie wykonywać podstawowych czynności dnia codziennego, takich jak mycie, ubieranie się, przygotowanie posiłków czy przyjmowanie leków o stałych porach. Pomocy niezbędnej w tej sytuacji nie da się zapewnić w formie usług opiekuńczych w miejscu zamieszkania. Usługi obejmują tylko część doby, a potrzebna jest obecność opiekuna również w nocy i w dni wolne. Rodzina nie ma możliwości zapewnienia całodobowej opieki ze względu na pracę zawodową, własny stan zdrowia i odległość od miejsca zamieszkania osoby ubiegającej się. Wobec powyższego zapewnienie niezbędnej pomocy w formie usług opiekuńczych w miejscu zamieszkania nie jest możliwe, co uzasadnia skierowanie do domu pomocy społecznej. Oświadczam, że wniosek składam za zgodą osoby ubiegającej się o skierowanie, zgodnie z § 8 ust. 1 pkt 1 powołanego rozporządzenia. Osoba ta wyraża zgodę na umieszczenie w domu pomocy społecznej oraz na ponoszenie opłaty za pobyt. Proszę o przeprowadzenie rodzinnego wywiadu środowiskowego i o wydanie decyzji o skierowaniu do domu pomocy społecznej. .................................... (czytelny podpis) Załączniki: 1. Zaświadczenie lekarskie o stanie zdrowia i o konieczności sprawowania całodobowej opieki 2. Decyzja organu emerytalno-rentowego ustalająca wysokość emerytury lub renty (ostatnia decyzja waloryzacyjna) 3. Oświadczenie o wysokości dochodu osoby ubiegającej się
Wydrukuj w dwóch egzemplarzach: jeden zostawiasz w urzędzie, na drugim prosisz o pieczątkę z datą wpływu. To Twój jedyny dowód, że pismo wpłynęło w terminie.
Kolejka do DPS bywa długa. Warto mieć plan awaryjny.
Powiedz nam, czego potrzebuje Twój bliski, a bezpłatnie dobierzemy placówki, które mają wolne miejsca teraz.
Znajdź dom opiekiWhat to do with the finished letter
The letter is a quarter of the job. Below is the path every application and every appeal goes through.
Application for a DPS referral step by step
Print it and sign by hand
The senior signs, or the person filing on their behalf with their consent. The signature has to be legible and handwritten - a scanned signature will not do.
File it with the MOPS or GOPS
The competent centre is the one covering the senior's place of residence or stay on the day of referral, not your address. You can file in person at the registry, by registered post, or through ePUAP.
Get ready for the home interview
A social worker will arrange a visit at the senior's home. This is the most important moment of the whole case: the interview has to include a written finding that the family and the commune cannot provide care services on site. Have the medical records and hospital discharge notes to hand.
Expect two decisions, not one
The commune issues a decision on the referral and a separate decision setting the fee. Check the income calculation in the second one, because that is where the errors usually are. Each can be appealed within 14 days.
Wait for the placement decision
The referral goes to the district, where the starosta issues a decision on placement in a specific home. Only then does the wait for a free place begin, and in larger cities it can run to many months.
Appealing a decision step by step
Check the delivery date, not the date of issue
You have 14 days from the day the decision was delivered. The date on the delivery confirmation is the only one that counts, and the gap between it and the date of issue can be a fortnight.
Write down exactly what you disagree with
Formally an appeal needs no detailed reasoning. In practice the board overturns decisions when it can see something concrete: an amount that does not match reality, or a document the first-instance body never looked at.
File the appeal at the MOPS, not at the board
You address the letter to the local government board of appeal but file it at the office that issued the decision. That office has 7 days to pass the case to the board, or to overturn its own decision if it accepts the appeal in full.
Keep proof that you filed it
A stamped copy from the registry, or the receipt for a registered letter. The deadline is met on the date of posting, not on the date the letter reaches the office - a distinction that costs many appeals.
Wait for the board's ruling
The board can uphold the decision, overturn it and rule on the merits itself, or send the case back for reconsideration. Its decision can be challenged before the voivodeship administrative court within 30 days.
What these letters rest on
Every sentence the generator adds to a letter has a provision behind it. The state of the law below is July 2026.
| Rule | Legal basis |
|---|---|
| The right to a place in a public care home | Art. 54 (1) of the Social Assistance Act of 12 March 2004. It applies to a person needing round-the-clock care because of age, illness or disability who cannot be given the necessary help in the form of home care services. |
| The form of the application and the documents required | § 8 of the Regulation of the Minister of Labour and Social Policy of 23 August 2012 on care homes (Journal of Laws 2025, item 51). A written application is enough - there is no single official form nationwide. |
| Someone other than the senior may file it | § 8 (1) (1) of the same regulation. With the applicant's consent, another natural or legal person may file it, as may the district family support centre or a social welfare centre. |
| Types of care home | Art. 56 of the Social Assistance Act. A person is referred to a home of the matching type, located as close as possible to their existing place of residence. |
| Who issues the decision | Art. 59 (1) - the referral decision and the fee decision are issued by the commune competent for the senior. Art. 59 (2) - the placement decision is issued by the commune or the starosta of the district running the home. |
| The home interview comes before the decision | Art. 106 and art. 107 of the Social Assistance Act and § 8 (1) (2) of the regulation. The interview has to contain a written finding that the family and the commune cannot provide care services at the place of residence. |
| Appeal to the board through the first-instance body | Art. 127 § 1 and § 2 and art. 129 § 1 and § 2 of the Code of Administrative Procedure of 14 June 1960. In social assistance matters the higher-instance body is the local government board of appeal (art. 17 (1) of the Code), and the appeal is filed through the body that issued the decision within 14 days of delivery. |
| How the deadline is counted | Art. 57 § 5 (2) of the Code - the deadline is met if the letter was posted at an office of the designated postal operator. Art. 57 § 4 - if the deadline ends on a Saturday or a statutory day off, it expires on the next working day. |
| An appeal needs no detailed reasoning | Art. 128 of the Code. It is enough that the letter shows the party is not satisfied with the decision. Fuller reasoning is optional and in practice simply improves the odds. |
| Waiving the fee for the stay | Art. 64 of the Social Assistance Act. A full or partial waiver follows an application by the person liable, after the circumstances listed in that provision are assessed. It is not automatic - it has to be asked for and documented. |
Common questions about the application and the appeal
- Does the DPS application have to be on an official form?
- There is no single binding form nationwide. The regulation simply requires a written application, so the letter from this generator is fully effective. Many centres have their own helper forms and will offer them - if the MOPS asks you to fill in theirs, copy the same details onto it and attach the generated letter as the reasoning.
- How long do I have to appeal a decision?
- 14 days from the day the decision was delivered, not from the date it was issued. The deadline is met if you post the letter at a Polish Post office on the last day - it does not have to reach the office that day. If the deadline ends on a Saturday or a public holiday, it moves to the next working day. If it has already passed, you can still file the appeal together with a request to restore the deadline, but you have to do it within seven days of the obstacle ending and show you were not at fault.
- Where do I file the appeal: at the board or at the MOPS?
- At the MOPS or GOPS, that is the body that issued the decision, even though the letter is addressed to the local government board of appeal. That is how art. 129 § 1 of the Code works and it is the most common mistake in these cases. The centre then has seven days to pass the file to the board, and if it finds the appeal fully justified it can overturn its own decision and issue a new one.
- Does the appeal have to contain reasoning?
- Formally no. Art. 128 of the Code says explicitly that an appeal needs no detailed reasoning and that it is enough for it to show the party is not satisfied with the decision. Practice is different: the board rules on the file, so every specific - an amount, a date, a document the office never had - genuinely improves the odds. That is why the generator adds objections and leaves room for your own account.
- Who can file if the senior cannot manage it?
- With the applicant's consent, another natural or legal person may file it, as may a social welfare centre or a district family support centre. So it is enough that the senior agrees, even if they cannot get to the office themselves. It is harder when consent cannot be obtained at all because of the state of health: the commune then has to apply to the guardianship court, which is a separate and far longer procedure.
- How much does it cost to file an application or an appeal?
- Nothing. Social assistance proceedings are exempt from stamp duty, and an appeal to the local government board of appeal is free as well. You do not need a lawyer either - these cases are normally run in person, and that is the rule rather than the exception.
- What happens after the application is filed?
- First a social worker carries out a family home interview at the senior's place of residence. Then the commune issues a decision on the referral and a separate decision setting the fee for the stay. The referral goes to the district, where the starosta issues a decision on placement in a specific home, and only then does the wait for a free place begin. The office is meant to settle the case within a month, or two for a particularly complex one, and it has to give written notice of any extension.
- What happens to the data I type into the generator?
- None of it leaves your browser. The letter is assembled from those fields on the device you are filling it in on; we do not send them to a server, do not store them and do not ask for an email address. Close the tab and the form is empty. If you would still rather not type the PESEL number, leave the field blank and write it on the printout by hand.
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This is a template, not legal advice
The generator assembles a letter from ready-made passages, based on the law in force in July 2026 and the details you provided. We do not know your case file, so we do not judge its chances or pick a strategy for you. In contested matters, especially where the fee for the stay is high or a waiver has been refused, it is worth showing the letter to a lawyer or to a free legal aid point in your district. Read the whole thing before filing and correct anything that does not match reality.
State of the law: July 2026