Fillable Application for SNAP and TEA (State of Arkansas)

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Application for SNAP and TEA (State of Arkansas)

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See if you qualify for SNAP and TEA online! Apply online at www.access.arkansas.gov!
The Supplemental Nutrition Assistance Program (SNAP) helps low-income people buy the food
they need for good health.
SNAP benefits supplement an individual’s or a family’s income to help
buy nutritious food. Most households must spend some of their own money along with their SNAP
benefits to buy the food they need.
You may be able to receive SNAP benefits if you are working for low wages; working part-time; unemployed;
receiving public assistance payments; living with a disability; are older; or homeless. All participants must meet
financial and non-financial criteria.
The Transitional Employment Assistance (TEA) Program helps economically needy families
with children under the age of 18 become more responsible for their own support and less
dependent on public assistance. TEA provides monthly cash assistance to eligible families to help
meet the family's basic needs. TEA also provides supportive services such as child care
assistance and employment related services while the parent or other adult relative works toward
increasing his or her earning potential. State law limits the receipt of TEA benefits to 24-month
lifetime limit.
Y
ou can have some income, including earnings, and still be eligible to receive TEA benefits, if your countable
income is less than the income standard. You can have resources (cash, bank accounts, property not used as a
home, etc.) if the total value of these resources does not exceed $3,000. TEA cash assistance is also available to
help meet the needs of children who are being cared for by non-parent adult relatives. Assistance to such
relatives may be provided for the children without regard to the time limit.
When should I apply?
It is important to turn in your application right away. If your household is eligible, your first month of SNAP
benefits will be paid from the day that your application was received online or the date you submit a paper
application in the DHS County Office. The TEA effective date of payment is the first day of the month your
application is approved.
You have the right to submit a SNAP application with only the applicant's name, address, and the
signature of a responsible household member or the household's authorized representative. However, providing a
complete application may result in a quicker eligibility determination.
Do you need help completing your application?
By Phone
Customer Assistance
1-800-482-8988
In Person
Contact your local DHS county office
for more information
En Español
Llame a nuestro centro
de ayuda gratis al
1-800-482-8988
Wrap-1 (Rev. 04/2020)
¡Ayuda
!
KEEP THE OUTER PORTION OF THIS APPLICATION FOR YOUR INFORMATION
Arkansas Department of Human Services
Application for SNAP and
TEA
(Food Assistance and Cash Assistance)
Wrap-2 (Rev. 8/2017)
Interview requirements for both SNAP and TEA:
Households applying for SNAP and TEA are required to complete an interview for their eligibility
determination. This interview can be in-person or over-the-phone. Households that apply online
at www.access.arkansas.gov
are automatically offered a telephone interview. Only one interview
is necessary when applying for both SNAP and TEA. If you miss your appointment for an
interview, we will not schedule another appointment unless you ask us to do so.
Your household may choose someone who knows about your circumstances to complete the interview either in-
person or over-the-phone. This person is called an “authorized representative”.
Helpful documents for SNAP and TEA:
A Social Security Number (SSN) or proof of application for an SSN for each household
member applying for benefits.
Documentation of legal alien status for each non-citizen applying for benefits.
Proof of identity for the applicant.
Proof of residence.
Proof of all income.
Proof of the value of resources such as, but not limited to, bank accounts, certificates of deposit, stocks,
bonds, and vehicles.
Proof of medical expenses for household members over the age of 60 or living with a disability, only if you
want these expenses to be claimed.
Proof of current utility bills, only if you want to use your actual utility costs to calculate your SNAP benefit
amount. NOTE: SNAP allows certain households to use a “utility standard.” Ask your worker if actual
costs or the utility standard will be best for your household.
If you are applying for TEA benefits for a child, proof of that child's age and proof of that child's relationship
to you.
A Drug Assessment Questionnaire (DAQ) must be completed for each adult household member applying
for TEA benefits.
How long does it take to process an application?
Most SNAP applications must be processed within 30 days. However, we must
process your SNAP application within seven days (expedited service) if:
Your household has $100 or less in cash, bank accounts, or other liquid
resources and less than $150 in countable income; OR
Your current shelter costs are more than your income and liquid resources; OR
You are a migrant or seasonal farm worker and your household has little or no income at the time you
apply.
TEA applications should be processed within 30 days.
If you complete the screening questions in the SNAP Expedited Service section, we will determine if your
household is entitled to expedited service in SNAP.
How will I know if my application has been approved or denied?
When we take action on your application for SNAP or TEA, we will send you a notice to tell you if your application
has been approved or denied.
If I am eligible, how will I get my benefits?
If you participate in the SNAP and/or the TEA Program, you will receive an electronic benefits
transfer (EBT) card that looks similar to a debit card. Your EBT card will be used to access your
SNAP and/or TEA benefits. SNAP benefits may only be accessed at authorized retailers, such as grocery stores
and approved farmers’ markets.
What are my appeal rights?
If you are not satisfied with our actions or if we fail to act on your application for SNAP or TEA, you or your
representative may ask for a hearing. There are three ways that you or your representative can request a
hearing.
1. You may request a hearing by following the instructions listed on the back of the Notice of Action form you
received regarding your application.
2. You may also ask for a hearing by calling the DHS County Office, writing a letter to the DHS County
Office, or going to the DHS County Office.
3. You may also request a hearing by writing or calling the Appeals and Hearings Section:
Arkansas Department of Human Services
ATTN: Appeals and Hearings Section
P.O. Box 1437, Slot N401
Little Rock, AR 72203-1437
Telephone - (501) 682-8622
TDD for Hearing Impaired – 501-682-6974
FAX - (501) 682-6605
Who is ineligible to participate in SNAP and/or TEA?
• Any individual currently classified as a fugitive felon, parole violator, or probation violator.
Note: If a household has a mix of eligible and ineligible individuals, the eligible individuals may receive SNAP benefits as
long as they meet all other program criteria.
Intentional Program Violations
Supplemental Nutrition Assistance Program
People who participate in the Supplemental Nutrition Assistance Program must follow these rules:
Do not give false information or withhold information in order to get or to continue to get SNAP benefits.
Do not alter any authorization document to get SNAP benefits you are not eligible to receive.
Do not use SNAP benefits to buy non-food items like alcoholic drinks, tobacco, or personal grooming items.
Do not trade or sell SNAP benefits or allow unauthorized use of electronic benefits transfer (EBT) cards.
Do not use someone else’s SNAP EBT card for your household’s benefit.
Do not buy or sell or attempt to buy or sell SNAP benefits or Electronic Benefits Transfer (EBT) cards for cash or for
consideration other than eligible foods in public and online. Buying and selling or attempting to buy or sell your EBT
card is called trafficking and may cause you to lose your benefits or be taken off the program permanently (forever).
An intentional program violation (IPV) occurs when you or any member of your household: 1)
Makes a false or misleading statement or misrepresents, conceals or withholds facts; or 2)
Commits any act that constitutes a violation of the Food and Nutrition Act, SNAP Regulations,
or State Statute for the purpose of using, presenting, transferring, acquiring, receiving,
possessing, or trafficking of SNAP authorization cards, or reusable documents used as part of
an automated benefit delivery system. Anyone found to have committed an IPV will be
disqualified from SNAP participation for: one year for the first violation, two years for the
second violation, and permanently for the third violation. He or she may also be fined or
imprisoned or both and may be subject to federal prosecution and penalties.
Special disqualification periods apply when an individual is found guilty of any of the following violations:
Making a fraudulent statement or representation about identity or residence in order to get SNAP
benefits in two locations during the same month – a ten-year disqualification.
Buying or selling controlled substances in exchange for
SNAP benefits – a 24-month
disqualification for the first violation and a permanent disqualification for the second violation.
Buying or selling firearms, ammunition, or explosives in exchange for
SNAP benefits – a
permanent disqualification.
Wrap-3 (Rev. 4/2020)
Trafficking SNAP benefits in excess of $500 – a permanent disqualification.
Intentional Program Violations
TEA Program
People who participate in TEA must follow these rules:
If you give any information that is false or misleading or if you withhold or conceal facts for the purpose of
establishing or maintaining your family's eligibility for TEA, you may be found guilty of committing an intentional
program violation (IPV) by an Administrative Hearing or through a court of law.
If you plead guilty or nolo contendere (no contest) or are found guilty of an IPV, your family will be ineligible for
TEA for one year for the first offense, two years for the second offense and permanently for any subsequent
offense. In addition, your family will remain ineligible to receive TEA benefits until the resulting overpayment is
repaid to the State.
If you are found guilty of giving false information about your residence in order to receive TANF assistance in two
or more states at the same time, your family will be ineligible for TEA assistance for a minimum of ten years
beginning with the date of conviction. (The TEA Program is Arkansas' TANF Program.)
Did you know that if you are eligible for SNAP or TEA, you may be eligible for the
following programs?
Housing assistance through HUD. Visit www.hud.gov for more information.
Assistance for utility costs through the Home Energy Assistance Program (HEAP). Visit www.acaaa.org to
learn which agency serves your county.
Certain Medicaid categories. Visit www.access.arkansas.gov or visit your local DHS county office to apply for
Medicaid.
Help with your telephone service through Lifeline and Link Up or visit www.lifelinesupport.org to apply. Ask
your current telephone provider for more information.
Free or reduced tax preparation service through certain companies. Contact your tax preparer to see if they
offer these services.
Free or reduced legal services. Contact local legal offices for a referral in your area.
Free school meals for children attending public schools. Children will be automatically enrolled through an
administrative matching program.
Your Right to Privacy
The PRIVACY ACT of 1974 requires the Department of Human Services (DHS) to tell you: (1) whether disclosure is voluntary
or mandatory; (2) how DHS will use your SSN; and, (3) the law or regulation that allows DHS to ask you for the SSN. We are
authorized to collect from your household certain information including the social security number (SSN) of each eligible
household member. For the Supplemental Nutrition Assistance Program this authority is granted under the Food and
Nutrition Act of 2008 as amended, 7 U.S.C. 2001-2036. For both the Medicaid Program and the TEA Program, this authority
is granted under Federal laws codified at 42 U.S.C. §§ 1320b-7(a)(1) and 1320b-7(b)(2). This information may be verified
through computer matching programs. We will use this information to determine program eligibility, to monitor compliance
with program rules, and for program management. This information may be disclosed to other Federal and State agencies
and to law enforcement officials. If claim arises against your household, the information on this application, including all
SSNs may be provided to Federal or State officials or to private agencies for collection purposes.
Wrap-4 (Rev 4/2020)
Arkansas Department of Human Services
Application for SNAP and TEA
IF YOU NEED THIS APPLICATION IN LARGE PRINT, CONTACT YOUR DHS OFFICE.
Si necesita este formulario en Español, llame al 1-800-482-8988 y pida la versión en Español.
Head of Household Name
Work Phone
Mailing Address
(P.O. Box, Street, Apt./Lot #)
City State Zip
Home or Cell Phone
Residence Address (Street, Apt./Lot #)
City State Zip
E-mail Address
What Services Are You Requesting? Please use blue or black ink.
Supplemental Nutrition Assistance Program (SNAP)
Are you currently receiving SNAP benefits? YES NO
If you believe your household needs SNAP benefits right away, complete the questions on page 2 of this form. If you
do, we can determine if you are entitled to receive SNAP benefits within 7 days.
Transitional Employment Assistance (TEA) for Households with Children Under 18
Are you currently receiving TEA? YES NO
Do you have a child under 18 living in your home? YES NO
1.
Have you or anyone in your household received assistance in another state?
YES NO
If yes, check all that apply.
SNAP TEA
2.
Do you have or have you ever had an electronic benefits transfer (EBT) card in Arkansas?
YES NO
If yes, do you currently have the card?
YES NO
3.
Would you prefer an in-person interview or an interview by telephone?
In-person
Telephone
If you selected a telephone interview, you must provide a working phone number. Be sure to
have phone service or minutes available.
4.
If not English, what language do you speak at home?
Do you need an interpreter?
YES NO
Household Members: List all the people who live in your home, including yourself. If needed, attach a sheet of paper listing
additional members.
Social
Security
Number
Full name
(First, middle, and last)
Birthdate
Relationship
to you
Does this
person buy and
prepare meals
separately?
Is this person a
U.S. Citizen?
YES
NO YES
NO
YES
NO
YES
NO
YES
NO YES
NO
Federal law requires that each state provide the opportunity to register to vote with every application for public assistance. Please answer the
following question regarding voter registration:
• Would you like to register to vote or change your voter registration address? Yes No
If you marked Yes, please complete and sign the Voter Registration Application that is attached. If you marked No, submit your application to your local
DHS County Office.
By my signature, I authorize the Arkansas Department of Human Services (DHS) to get information from other state agencies, financial institutions,
employers, federal agencies, and other sources to prove my statements are correct. I understand that if differences are found between what I report and
information provided by the sources listed above, DHS may contact other sources for verification. I understand that this information may affect my
household’s eligibility for benefits. I understand that if required, I must cooperate with the Office of Child Support Enforcement as a condition of
eligibility. I certify, under penalty of perjury, that the information I have reported, as shown on this form is correct to the best of my knowledge.
Signature: Date:
Signature of Witness if applicant signs with an “X”:
Some SNAP applicants are entitled to receive SNAP benefits within seven days (expedited service).
The answers to the questions below will help us screen your household for SNAP expedited service.
Answer each question for yourself and all other household members.
1 DCO-215 (Rev. 4/2020)
SNAP Expedited Service for All Households:
1.
What is your household’s total monthly income before deductions?
Deductions are amounts taken out for taxes, insurance, etc. The monthly total must include
money that you and other household members receive from work and money received in the
form of checks or cash. Also, you must include money that you and other members of your
household have already received so far this month and money that you will be receiving before
the end of the month.
$
2.
How much money do you and other household members currently have in cash, checking
accounts, savings accounts, etc.?
$
3.
How much are your household’s monthly housing and utility costs?
Regular amounts only. Do not include past due totals.
$
SNAP Expedited Service for Households with Migrant or Seasonal Farm Workers:
1.
Is anyone in your household a migrant or a seasonal farm worker?
YES NO
2.
Did your household’s income recently stop?
YES NO
3.
Do you or anyone else in your household expect income from a new source this month?
YES NO
(A) If yes, how much will the income be?
$
(B) When do you expect to receive the income?
DATE:
County Use Only
Expedited:
YES NO
Screener: Screen Date: LD Date:
Notes:
Ethnicity Declaration: DHS is required to ask for racial and ethnic data on households applying for or participating in
SNAP. You are not required to complete this section in order to receive assistance. If you are approved, your benefit level
will not be affected by your decision to complete or not complete this section. DHS encourages you to answer the questions
below
. Are you Hispanic or Latino? (Select only one) YES NO
What is your race? (Select one or more)
American Indian or Alaskan
Native
Pacific Islander or Native Hawaiian
Asian
Black or African
American
White
Other
Income: Please check each type of income that you and anyone living in your home currently receives.
Wages/Salary/Earnings
Unemployment Benefits
Training Allowances
SSA or SSI Income
Worker’s Compensation/Sick Pay
Interest Income
Retirement/Pension/Annuity
Self-employment Income
Americorp VISTA/Americorp Program
Income
Child Support/Alimony
Military Allotment
Cash Contributions
Railroad or Veteran’s benefits
Income from rental property
Other
Resources
Checking/Savings Account
Campers/RV (Motor Home)
Stocks/Bonds/Mutual Funds
Trust Fund
Motorcycle or ATV
Mobile Home
Certificate of Deposit (CD)
Golf cart/ Go-cart/ Moped
Burial Plots/Prepaid Plan
Christmas Club Account
Car/Truck/Van
Real Estate (not your home)
IRA/ KEOGH/ 401K
Boats/ Motors/Trailers
Other
Have you or anyone in your home sold or given away any resource in the past 3 months? YES NO
Have you received cash gifts, awards, or prizes of at least $3,500 or more within the last three months? YES NO
Have you won the lottery totaling at least $3,500 or more? YES NO
Expenses: Please check each type of expense that you or anyone else in your home pays.
Rent
Insurance on home
Baby sitter or day care
Mortgage Payment
Utilities
Medical costs
Taxes on home
Telephone
Child support
Failure to report and verify any of the above listed expenses will be seen as a statement by your household that you do not
want to receive a deduction for unreported expenses.
2 DCO-215 (Rev. 4/2020)
Students: Is anyone in your home currently enrolled in a college, vocational school, technical school or any
other training program beyond high school? YES NO If yes, complete the section below.
1.
Name of student
2.
School or training program
3.
Enrollment status
Full-time Part-time
4.
Is the student a Work-Study Program participant?
YES NO
Mandatory Cooperation with Child Support Enforcement: If you check YES to the questions below,
you must provide the names of the parent and child(ren). Failure to provide correct information could be fraud. If
you have good cause not to cooperate with Child Support Enforcement, you must tell your eligibility worker. You
will be asked to provide evidence to help determine if you have good cause.
Custodial Parent
Non-Custodial Parent
Does anyone in the household have a court
order for child support?
Yes No
Does anyone in the household
have any minor children living
outside of the home?
Yes No
Is anyone in the household
required to make child support
payments?
Yes No
Authorized Representative: If you want to choose someone to represent you, please complete the following
information. If you name an authorized representative, this person will be able to take your place at the interview and talk to
the DHS county worker on your behalf.
Name
Mailing Address (P.O. Box, Street, Apt./Lot #)
City State Zip
Home or Cell Phone
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its
Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating
based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity
in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,
American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard
of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program
information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter
all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or
letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3)
email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Providing a Social Security Number and/or information about citizenship or immigration status is voluntary. However, anyone who fails or
refuses to provide any of this information will not be eligible to receive SNAP and/or TEA benefits. Other household members who do
provide this information may participate in SNAP and/or TEA, if the household is found to be eligible.
If you are age 18 or over or 49 or under and get SNAP benefits you must also meet the Requirement To Work or the RTW rule unless
exempt from the RTW or Work Registration. The RTW rule only applies to Able Bodied Adults without Dependents or ABAWDs who
are 18 or over or 49 or under. If the work requirements of this rule are not met, then an ABAWD can only receive SNAP benefits for 3
months out of a 3-year period. However, if work requirements are met, benefits may continue. Your caseworker can provide more
information.
You can continue to receive SNAP benefits as long as you are eligible under Program rules. This is true even if someone in your home
receives TEA/Works Pays cash assistance. If someone in your home does receive TEA/Works Pays cash assistance, participation in
SNAP will not count against their TEA/Works Pays time limits.
Providing Information - You must declare Social Security Numbers for everyone who will receive benefits. Bringing items such as your
most recent paycheck stubs, award letters, and bank statements to your interview may speed up the application process. During the
interview, the DHS worker will tell you if you must provide any additional information.
3 DCO-215 (Rev. 4/2020)
DHS County Office Mailing Addresses
County
Address
City
Zip
County
Address
City
Zip
County
Address
City
Zip
Arkansas
100 Court Square
DeWitt
72042
Grant
PO Box 158
Sheridan
72150
Ouachita
PO Box 718
Camden
71711
Arkansas
PO Box 1008
Stuttgart
72160
Greene
809 Goldsmith Road
Paragould
72450
Perry
213 Houston Ave.
Perryville
72126
Ashley
PO Box 190
Hamburg
71646
Hempstead
116 N. Laurel
Hope
71801
Phillips
PO Box 277
Helena
72342
Baxter
PO Box 408
Mt. Home
72654
Hot Spring
2505 Pine Bluff St.
Malvern
72104
Pike
PO Box 200
Murfreesboro
71958
Benton
900 SE 13th Court
Bentonville
72712
Howard
PO Box 1740
Nashville
71852
Poinsett
PO Box 526
Harrisburg
72432
Boone
PO Box 1096
Harrison
72601
Independence
100 Weaver Ave
Batesville
72501
Polk
P.O. Box 1808
Mena
71953
Bradley
PO Box 509
Warren
71671
Izard
PO Box 65
Melbourne
72556
Pope
701 N. Denver
Russellville
72801
Calhoun
PO Box 1068
Hampton
71744
Jackson
PO Box 610
Newport
72112
Prairie
PO Box 356
DeValls Bluff
72041
Carroll
PO Box 425
Berryville
72616
Jefferson
PO Box 5670
Pine Bluff
71611
Pulaski East
PO Box 8083
Little Rock
72203
Chicot
PO Box 71
Lake Village
71653
Johnson
PO Box 1636
Clarksville
72830
Pulaski Jax.
PO Box 626
Jacksonville
72078
Clark
PO Box 969
Arkadelphia
71923
Lafayette
2612 Spruce St.
Lewisville
71845
Pulaski No.
PO Box 5791
N. Little Rock
72119
Clay
PO Box 366
Piggott
72454
Lawrence
PO Box 69
Walnut Ridge
72476
Pulaski So.
PO Box 2620
Little Rock
72203
Cleburne
PO Box 1140
Heber Springs.
72543
Lee
PO Box 309
Marianna
72360
Pulaski Sw.
PO Box 8916
Little Rock
72219
Cleveland
PO Box 465
Rison
71665
Lincoln
101 W. Wiley St.
Star City
71667
Randolph
1408 Pace Rd.
Pocahontas
72455
Columbia
PO Box 1109
Magnolia
71754
Little River
90 Waddell St.
Ashdown
71822
Saline
1603 Edison Ave.
Benton
72018
Conway
PO Box 228
Morrilton
72110
Logan-1
#17 W. McKeen
Paris
72855
Scott
PO Box 840
Waldron
72958
Craighead
PO Box 16840
Jonesboro
72403
Logan-2
398 E. 2nd St.
Booneville
72927
Searcy
106 School St.
Marshall
72650
Crawford
704 Cloverleaf Circle
Van Buren
72956
Lonoke
PO Box 260
Lonoke
72086
Sebastian
616 Garrison
Ft. Smith
72901
Crittenden
401 S. College Blvd
W. Memphis
72301
Madison
PO Box 128
Huntsville
72740
Sevier
PO Box 670
DeQueen
71832
Cross
803 E. Hwy 64
Wynne
72396
Marion
PO Box 447
Yellville
72687
Sharp
1467 Hwy 62/412
Ste. B
Cherokee
Village
75229
Dallas
1202 W. 3rd St.
Fordyce
71742
Miller
3809 Airport Plaza
Texarkana
71854
St Francis
PO Box 899
Forrest City
72336
Desha
PO Box 1009
McGehee
71654
Mississippi 1
1104 Byrum Rd.
Blytheville
72315
Stone
1821 E Main
Mountain View
72560
Drew
PO Box 1350
Monticello
71657
Mississippi 2
437 S Country Club
Osceola
72370
Union
123 W. 18th St.
El Dorado
71730
Faulkner
1000 E.
Siebenmorgan
Conway
72032
Monroe-1
PO Box 354
Clarendon
72029
Van Buren
449 Ingram St.
Clinton
72031
Franklin
800 W Commercial
Ozark
72949
Monroe-2
301½ N New Orleans
Brinkley
72021
Washington
4044 Frontage
Fayetteville
72703
Fulton
PO Box 650
Salem
72576
Montgomery
PO Box 445
Mt. Ida
71957
White
608 Rodgers Drive
Searcy
72143
Garland
115 Stover Lane
Hot Springs
71913
Nevada
PO Box 292
Prescott
71857
Woodruff
PO Box 493
Augusta
72006
Newton
PO Box 452
Jasper
72641
Yell
PO Box 277
Danville
72833
Fold in half and tape ends together.
Use the addresses above to mail your application to your local DHS County Office
Return Address
Place
Stamp
Here
VII), and
Each adult household member must complete the Drug Assessment questionnaire before TEA and/or Work Pays
eligibility can be determined.
State of Arkansas
WORKFORCESERVICES
TANF
DRUG ASSESSMENT TOOL
Participant’s
Name
(Please print)
Case #
Effective January 1, 2016, in accordance with Act 1205 of 2015, all adult (above 18) TANF applicants/recipients who are
otherwise eligible for TANF assistance are required to be assessed for illegal use of a controlled substance. If the
applicant/recipient is suspected of illegal drug use, he/she will have to undergo a drug test and potentially a substance
abuse treatment. If the applicant/recipient fails to comply with any of these requirements, the TANF case will be
denied/closed or the case will be approved with a protective payee in place.
Illegal use of a controlled substance (illegal drug) means:
The use of a drug that is against the law, or
The use of a prescription drug which is a controlled substance that is not prescribed for you.
Each person age 18 or older in your household case must
answer the following questions.
Return Date
SIGN AND DATE THIS FORM
I understand the drug assessment procedures as detailed in this form and will answer each question listed below
truthfully.
Applicant’s
Signature
Date
ANSWER EACH OF THE FOLLOWING QUESTIONS
YES
NO
In the past 30 days have you used any illegal drugs?
YES
NO
In the past 30 days have you lost or been denied a job due to current illegal drug use?
TANF- DRUG SCREENING QUESTIONNAIRE (09/2018)
ADWS and DHS are Equal Opportunity Providers / Employers | Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI &
the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of
1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color,
religion, sex national origin age, and disability. The Department must make a reasonable accommodation to allow a person with a
disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign
language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the
Department will take any other reasonable action that allows you to take part in and understand a program or activity, including
making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity
because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in
alternative format or for further information about this policy, contact your local office manager.
IMPORTANT INFORMATION FOR YOU
If you do not fill out this form and return it to DHS by the return date above, your application will be denied.
If you are a recipient, your case will be closed. We will send you a separate notice if we take this action.
While getting cash assistance, adult household members may have to complete a drug test if there is reasonable
cause to believe they are using illegal drugs.
If you test positive for illegal drugs, you must cooperate with drug testing requirements and your Plan of Action
or your case will be denied/closed or processed with a protective payee in place.
VII), and
Each adult household member must complete the Drug Assessment questionnaire before TEA and/or Work Pays
eligibility can be determined.
State of Arkansas
WORKFORCESERVICES
TANF
DRUG ASSESSMENT TOOL
Participant’s
Name
(Please print)
Case #
Effective January 1, 2016, in accordance with Act 1205 of 2015, all adult (above 18) TANF applicants/recipients who are
otherwise eligible for TANF assistance are required to be assessed for illegal use of a controlled substance. If the
applicant/recipient is suspected of illegal drug usage, he/she will have to undergo a drug test and potentially a substance
abuse treatment. If the applicant/recipient fails to comply with any of these requirements, the TANF case will be
denied/closed or the case will be approved with a protective payee in place.
Illegal use of a controlled substance (illegal drug) means:
The use of a drug that is against the law, or
The use of a prescription drug which is a controlled substance that is not prescribed for you.
Each person age 18 or older in your household case must
answer the following questions.
Return Date
SIGN AND DATE THIS FORM
I understand the drug assessment procedures as detailed in this form and will answer each question listed below
truthfully.
Applicant’s
Signature
Date
ANSWER EACH OF THE FOLLOWING QUESTIONS
YES
NO
In the past 30 days have you used any illegal drugs?
YES
NO
In the past 30 days have you lost or been denied a job due to current illegal drug use?
TANF- DRUG SCREENING QUESTIONNAIRE (09/2018)
ADWS and DHS are Equal Opportunity Providers / Employers | Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI &
the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of
1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color,
religion, sex national origin age, and disability. The Department must make a reasonable accommodation to allow a person with a
disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign
language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the
Department will take any other reasonable action that allows you to take part in and understand a program or activity, including
making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity
because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in
alternative format or for further information about this policy, contact your local office manager.
IMPORTANT INFORMATION FOR YOU
If you do not fill out this form and return it to DHS by the return date above, your application will be denied.
If you are a recipient, your case will be closed. We will send you a separate notice if we take this action.
While getting cash assistance, adult household members may have to complete a drug test if there is reasonable
cause to believe they are using illegal drugs.
If you test positive for illegal drugs, you must cooperate with drug testing requirements and your Plan of Action
or your case will be denied/closed or processed with a protective payee in place.
____
____
____
____
PLEASE PRINT AND USE BLACK INK TO COMPLETE
Rev. 6-13-17
ARKANSAS VOTER REGISTRATION APPLICATION
Check all that apply:
This is a new registration.
This is a name change.
This is an address change.
This is a party change.
Office Use Only
Assigned ID
1
Mr.
Mrs.
Miss
Ms.
Last Name
Jr. Sr.
II. III. IV.
First Name
Middle Name
2
Address Where You Live (See Section “C” Below)
(Rural addresses must draw map.)
Apt. or Lot#
City/Town
County
State
ZIP Code
3
Address Where You Receive Mail If Different From Above
Apt. or Lot#
City/Town
County
State
ZIP Code
4
Date of Birth /
Month
Day
/
Year
5
Home & Work Phone Numbers (Optional)
(H) (W)
6
Party Affiliation (Optional)
7
E-mail Address (Optional)
8
Have you ever voted in a federal election in this State? Yes No
Signature of elector - Please sign full name or put mark.
The information I have provided is true to the best of my knowledge. I do not claim the
right
to vote in another county or state. If I have provided false information, I may be subject to a
fine of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.
9
ID Number - Check the applicable box and provide the appropriate number.
Arkansas Driver’s license number
If you do not have a driver’s license provide the last 4 digits of social
security number
I have neither a driver’s license nor social security number.
10
(A) Are you a citizen of the United States of America and an Arkansas resident?
Yes No
(B) Will you be eighteen (18) years of age or older on or before election day?
Yes No
(C) Are you presently adjudged mentally incompetent by a court of competent jurisdiction?
Yes No
(D) Have you ever been convicted of a felony without your sentence having been
discharged or pardoned?
Yes No
If you checked No in response to either questions A or B, do not complete this form.
If you checked Yes in response to either questions C or D, do not complete this form.
11
Date: / /
Month Day Year
If applicant is unable to sign his/her name, provide name, address and phone
number of the person providing assistance:
Name Address:
City: State: Phone#:
Please complete the sections below if: MAIL REGISTRANTS: PLEASE SEE SECTION D.
• You were previously registered in another county or state, or
• You wish to change the name or address on your current registration.
Agency Code (For Official Use Only)
PA 04
Date of Birth
/ /
Month Day Year
A
Mr.
Mrs.
Miss
Ms.
Previous Last Name
Jr. Sr.
II. III. IV.
First Name
Middle Name
B
Previous House Number and Street Name
Apt. or Lot#
City/Town
County
State
ZIP Code
• Write in the names of the crossroads (or streets) nearest where you live.
•
Draw an “X” to show where you live.
• Use a dot to show any schools, churches, stores or other landmarks near
where you live and write the name of the landmark.
NORTH
X
• Public School
Woodchuck Road
Example
C
IDENTIFICATION REQUIREMENTS
IMPORTANT: Applicants will be required to
verify
their registration when voting in person or by
absentee ballot by providing a required document or
identification card as provided in Arkansas
Constitution, Amendment 51, Section 13. If your
voter registration application form is submitted by
mail
and you are registering for the first time, and
you do not have a valid Arkansas driver’s license
number or social security number,
in order to avoid
the additional identification requirements upon
voting for the first time you must submit with the
mailed
registration form: (a) a current and valid
photo identification; or (b) a copy of a current utility
bill, bank statement, government check, paycheck,
or other government document that shows your
name and address.
D
• Grocery
Store
If you live in a rural area but do not have a house or street number,
or if you have no address, please show on the map where you live.
Route #2
Deadline Information
To qualify to vote in the next election, you must apply to register to vote 30 days before the
election. If you mail this form, it must be postmarked by that date. You may also present it to a
voter registration agency representative by that date. If you miss the deadline you will not be
registered in time to vote in that election. Please don’t delay. Make sure your vote counts.
If you are qualified and the information on your form is complete, you will be notified of your
voting precinct by your local County Clerk.
To Mail
Fold form on middle perforation, remove plastic strip, seal at bottom, stamp and mail.
Questions?
Call your local County Clerk
or
Arkansas Secretary of State
Mark Martin
Elections Division – Voter
Services 1-800-482-1127
Contact your County Clerk if you have not received confirmation
of this application within two weeks.
ARKANSAS VOTER REGISTRATION INFORMATION
Section 7 of the National Voter Registration Act (NVRA) of 1993 requires that each state provide the
opportunity to register to vote with every application for public assistance and every recertification,
renewal and change of address. This Voter Registration packet is an opportunity for you to register to
vote or change your voter registration address. Applying to register or declining to register to vote will
not affect the amount of assistance that you will be provided by this agency.
If you would like help in filling out the voter registration application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the voter registration application
form in private.
No information relating to a declination to register to vote in connection with an application may
be used for any purpose other than voter registration.
If you believe that someone has interfered with your right to: 1) Register to vote;
2)
Decline to register to vote; 3) Privacy in deciding whether to register or in applying to register to
vote; or 4) Choose your own political party or other political preference,
You may file a complaint with:
Secretary of State
Room 256 State Capitol
Little Rock, Arkansas 72201
1-800-482-1127
Mailing Instructions for Voter Registration
You have two options to submit your Voter Registration form.
1.
You can submit the registration form in person or mail the registration form along with your
SNAP or Medicaid application to your local county DHS office. The address for your county
office can be found on the last page of this packet. Some applications (DCO-151 & DCO-152)
must be mailed to the Jefferson County DHS office. If you are using one of these forms, you
can mail the Voter Registration form with your application to that office. Upon receipt at any
county office, that office will mail the form to the Secretary of State’s office for you.
2.
You may also mail the Voter Registration form directly to the Secretary of State’s Office. To
mail the form directly to the Secretary of State’s office, separate the form from your
application/renewal, fold the form along the middle perforation, seal the bottom with tape or
staple, and mail to the address on the form. A stamp or stamped envelope is required for
mailing.
DCO-0137 (R. 04/15)
DHS County Office Mailing Addresses
County
Address
City
Zip
County
Address
City
Zip
County
Address
City
Zip
Arkansas
100 Court Square
DeWitt
72042
Grant
PO Box 158
Sheridan
72150
Ouachita
PO Box 718
Camden
71711
Arkansas PO Box 1008 Stuttgart 72160 Greene 809 Goldsmith Rd Paragould 72450 Perry 213 Houston Ave Perryville 72126
Ashley PO Box 190 Hamburg 71646 Hempstead 116 N. Laurel Hope 71802 Phillips PO Box 277 Helena 72342
Baxter PO Box 408 Mt. Home 72654 Hot Spring 2505 Pine Bluff St Malvern 72104 Pike PO Box 200 Murfreesboro 71958
Benton 900 SE 13
th
Court Bentonville 72712 Howard PO Box 1740 Nashville 71852 Poinsett PO Box 526 Harrisburg 72432
Boone PO Box 1096 Harrison 72602 Independence 100 Weaver Ave Batesville 72501 Polk PO Box 1808 Mena 71953
Bradley PO Box 509 Warren 71671 Izard PO Box 65 Melbourne 72556 Pope 701 N Denver Russellville 72801
Calhoun PO Box 1068 Hampton 71744 Jackson PO Box 610 Newport 72112 Prairie PO Box 356 DeValls Bluff 72041
Carroll PO Box 425 Berryville 72616 Jefferson PO Box 5670 Pine Bluff 71611 Pulaski East PO Box 8083 Little Rock 72203
Chicot PO Box 71 Lake Village 71653 Johnson PO Box 1636 Clarksville 72830 Pulaski Jax. PO Box 626 Jacksonville 72078
Clark PO Box 969 Arkadelphia 71923 Lafayette 2612 Spruce St. Lewisville 71845 Pulaski No. PO Box 5791 N. Little Rock 72119
Clay PO Box 366 Piggott 72454 Lawrence PO Box 69 Walnut Ridge 72476 Pulaski So. PO Box 2620 Little Rock 72203
Cleburne PO Box 1140 Heber Springs. 72543 Lee PO Box 309 Marianna 72360 Pulaski Sw. PO Box 8916 Little Rock 72219
Cleveland PO Box 465 Rison 71665 Lincoln 101 W. Wiley St. Star City 71667 Randolph 1408 Pace Rd Pocahontas 72455
Columbia PO Box 1109 Magnolia 71754 Little River 90 Waddell St. Ashdown 71822 Saline PO Box 608 Benton 72018
Conway PO Box 228 Morrilton 72110 Logan-1 #17 W. McKeen Paris 72855 Scott PO Box 840 Waldron 72958
Craighead PO Box 16840 Jonesboro 72403 Logan-2 398 East 2
nd
St. Booneville 72927 Searcy 106 School St Marshall 72650
Crawford 704 Cloverleaf Circle Van Buren 72956 Lonoke PO Box 260 Lonoke 72086 Sebastian 616 Garrison Ave Ft. Smith 72901
Crittenden 401 S. College Blvd W. Memphis 72301 Madison PO Box 128 Huntsville 72740 Sevier
PO Box 670
DeQueen 71832
Cross
803 Hwy 64E
Wynne
72396
Marion
PO Box 447
Yellville
72687
Sharp
1467 Hwy 62/412
Cherokee Village
72529
Ste. B
Dallas 1202 W. 3
rd
St. Fordyce 71742 Miller 3809 Airport Plaza Texarkana 71854 St Francis PO Box 899 Forrest City 72336
Desha PO Box 1009 McGehee 71654 Mississippi 1 1104 Byrum Rd. Blytheville 72315 Stone 1821 E Main Mountain View 72560
Drew PO Box 1350 Monticello 71657 Mississippi 2 437 S Country Club Osceola 72370 Union 123 W 18
th
St. El Dorado 71730
Faulkner
1000 East
Conway
72032
Monroe-1
PO Box 354
Clarendon
72029
Van Buren
449 Ingram Street
Clinton
72031
Siebenmorgan Road
Franklin 800 W Commercial Ozark 72949 Monroe-2 301½ N New Orleans Brinkley 72021 Washington 4044 Frontage Fayetteville 72703
Fulton PO Box 650 Salem 72576 Montgomery PO Box 445 Mount Ida 71957 White 608 Rodgers Drive Searcy 72143
Garland 115 Stover Lane Hot Springs 71913 Nevada PO Box 292 Prescott 71857 Woodruff PO Box 493 Augusta 72006
Newton PO Box 452 Jasper 72641 Yell PO Box 277 Danville 72833
*If you live in Pulaski County please check the zip code listing below to ensure that you mail or return your
application to the appropriate Pulaski County DHS Office.
Pulaski East : 72016, 72053, 72126, 72135, 72201, 72202, 72203, 72205, 72207, 72212, 72223, 72227
Pulaski North: 72046 (England), 72113, 72114, 72115, 72117, 72118, 72119, 72142 (Scott), 72190, 72231
Pulaski Jacksonville: 72023 (Cabot), 72076, 72078, 72099, 72106, 72116, 72120, 72124
Pulaski South: 72204, 72206 (Shared with Southwest)
Pulaski Southwest: 72002, 72065, 72103, 72208, 72209, 72210, 72211, 72164, 72180, 72183, 72206 (Shared with South)
DCO-0137 (R. 04/15)
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Application for SNAP and TEA (State of Arkansas)

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Completed 5 December 2021

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