Fillable Arkansas Department of Human Services Division of County (State of Arkansas)

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Arkansas Department of Human Services Division of County (State of Arkansas)

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DCO-234 (rev. 12/18) 1
County Office Address & Phone Number
Arkansas Department of Human Services
Division of County Operations
CHANGE REPORT
IF YOU NEED THIS INFORMATION IN A DIFFERENT FORMAT
SUCH AS LARGE PRINT, CONTACT THE DHS COUNTY OFFICE.
(Si necesita este formulario en Español, llame al 1-800-482-8988 y pida la
versión en Español.)
Y
ou may call or email the DHS County Office at the phone number or
webmail address shown to report changes for your TEA, Medicaid, or SNAP case(s). Please use the toll-free number
provided if the DHS County Office number is long distance.
Name: _______________________________________________ Date of Birth:_______________________
Budget Unit ID Number: ______________________Medicaid ID Number:__________________________
Check all that you receive: TEA Medicaid SNAP
Enter your _______________________________ Phone # __________________________________
Address: _______________________________ Hearing Impaired Phone # __________________
_______________________________ E-mail address ____________________________
Is this a new address? YES NO NOTE: If you have moved, you must complete Section 5.
If your address changes, you should report your new address to us at once or you may not receive important
correspondence from DHS.
INSTRUCTIONS: You may use this form to report the following changes in your household's circumstances.
SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM ONLY
You must report changes in your total household
i
ncome when it exceeds the limit for your househol
d
s
ize. (You do not have to report changes in your TEA
benefit amount.)
You must report increases in your household's cash
and savings if the total cash and savings of all
household members now equals or exceeds $2,250 or
more.
TEA AND MEDICAID PROGRAMS ONLY
You must report any change in income you receive
regardless of the amount received or how often y
ou
e
xpect to receive it
.
For Medicaid, you must report increases in your
household's savings if the total amounts to $2,000 or
more.
For TEA Cash Assistance, you must report increases
i
n your household's savings if the total amount
exceeds $3,000.
The following changes must be reported in the following Programs: SNAP, Medicaid and TEA Cash Assistance
You must report changes in any source of income.
You must report cars, or other licensed vehicles if
anyone in your home get one.
You must report changes in the number of people i
n
y
our household.
You must report changes in your work activities or
exemptions.
You must report if you move to a new residence.
If you move, you must report your new rent (or
mortgage) and utility costs.
You should always report any address changes even if
you do not move.
NOTICE TO SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM HOUSEHOLDS SUBJECT TO
SEMI-ANNUAL REPORTING OR ANNUAL REVIEW: See the ADDENDUM for an explanation of your reporting
requirements. You may use this Change Report to report if your income begins to exceed the limit for your household
size or if certain people in your home begin working less than 20 hours per week. Those are the changes that you are
required to report. However, you may use this form to report a change if you would like to do so. YOU OR ANYONE
IN YOUR HOME WHO GETS CASH ASSISTANCE OR MEDICAID MUST CONTINUE TO REPORT CHANGES
AS SHOWN ABOVE. IF THESE CHANGES AFFECT YOUR SNAP CASE, WE WILL LET YOU KNOW.
DCO-234 (rev. 12/18) 2
SECTION 1 - DID YOUR INCOME CHANGE?
New Income: Complete this section if you or anyone in your household started working or began getting income from a
new source. Report the income of new members here.
Name of Household Member
Source of New Income
(Company, Agency, Person, etc.)
Date Income Was
First Received
Amount
$
Income Stopped: Complete this section if you or anyone in your household stopped working or income stopped from any source.
Name of Household Member
Date Income Was
Last Received
Reason Income Stopped
Income Went Up or Down: Complete this section if income received by you or anyone else in your household changed.
Name of Household Member
Source of Income That Changed
(Company, Agency, Person, etc.)
Date Income
Changed
New
Amount
How Often
Received?
$
Required Proof: You must send proof of the change in income. Send award letters, check stubs, cash receipts, or any other
documentation that shows the new amount of income, and for income that stopped, the last date paid. If your income from work
changed, send proof of all cash, checks, etc. received in the last 30 days.
SECTION 2 - DID YOUR SAVINGS INCREASE?
You must tell us if the total amount of money that you or anyone else in your household has in liquid resources (cash, savings
accounts, checking accounts, stocks, bonds, etc.) increases to $2,250 if you receive SNAP benefits, to $2,000 or more if you receive
Medicaid, or to more than $3,000 if you receive TEA cash assistance. This includes all accounts with the name of a household
member on the account even if the money belongs to someone else.
State the current amount of your liquid resources. $_________________
SECTION 3 - DID YOU GET A NEW VEHICLE?
If you or anyone in your household purchased, leases, or was given a car, truck,
boat, camper, motorcycle or other vehicle, you must report the make, model and
year of the new vehicle. This includes both licensed and unlicensed vehicles.
If a vehicle was sold or traded at the same time,
you may wish to tell us the make, model, and
year of the vehicle that was sold or traded.
Make
Model
Year
Licensed
Value
Make
Model
Year
YES NO
$
SECTION 4 - DID YOUR HOUSEHOLD COMPOSITION CHANGE?
If a member of your household moved out or passed away, you must complete this section. (Use a sheet of paper if you need more room to
report.)
Name of Member Who is
NO Longer in Home
Date Member
Left Home
Social Security
Number
Date of
Birth
State Reason Member is
NO Longer in Home
If someone moved into your home or if a member of your household had a baby, you must complete this section. (Use a sheet of
paper if you need more room to report.) Each new household member must declare a social security number and/or citizenship status
before he or she is allowed to receive benefits. Also, you must complete the information on page 3 of this form.
Name of New Household Member
Date Member
Entered Home
Social Security
Number
Date of
Birth
Relationship
U.S.
Citizen
Legal
Alien
Are new members currently receiving SNAP, Medicaid, and/or TEA cash assistance? YES
NO
If yes, who is receiving benefits? ____________________ Where are they getting benefits?________________________
What benefits do they receive?_________________________________________________________________________
If not receiving benefits, does this new member need health coverage? YES NO
Are any new members pregnant? YES
NO
If Yes, expected due date?________________ (mm/dd/yyyy)
Number of babies expected in the pregnancy?___________
Do the new members plan to file a federal income tax return NEXT YEAR? YES
NO
Will they file jointly with a spouse? YES
NO
If Yes, name of spouse:____________________________________
Will they claim any dependents on their tax return? YES
NO
If Yes, list names of dependents:________________
__________________________________________________________________________________________________
Will the new household member be claimed as a dependent on someone’s tax return? YES
NO
If Yes, please list the name of the tax filer: _____________________How are they related to the tax filer?_____________
If the new household member is a minor child with an absent parent, please provide the absent parent’s information:
First Name: ________________________ Last Name: ______________________________ Social Security Number (SSN): _ _ _ - _ _ - _ _ _ _
Date of birth (mm/dd/yy) _ _ / _ _ / _ _ Address: ___________________________________________________________________________
Phone: (_____) ________________ Relationship to child: ______________________ Why is the parent absent from home? _______________
DCO-234 (rev. 12/18) 3
You may claim to have good cause for refusing to provide absent parent information if you believe that it would not be in the best interest of you or
your child(ren). You must provide evidence to support this good cause claim. Would you like to claim good cause?
YES
NO
If yes, please
provide your good cause reason:
________________________________________________
SECTION 5 - SNAP HOUSEHOLDS ONLY - DID YOU MOVE TO A NEW RESIDENCE?
Check here if you moved to a new residence:
Check here if your address changed:
Enter new rent or mortgage payment here: $________
If yes, give your new address:
Enter insurance on home here: $________
(If not included in payment)
_________________________________________
_________________________________________
Enter annual real estate taxes here: $________
(If not included in payment)
Home Phone______________________________
Message Phone ____________________________
List your new utility costs:
Heating fuel (Butane, natural gas, etc.) $__________
Electricity $__________ Water/Sewer $__________
Telephone $__________ Garbage Pickup $__________
Other $__________ - Explain ___________________
Will you be using an air conditioner? YES
NO
How will you be heating your home?
W
ill anyone be paying part of your shelter costs?
YES NO If yes, who? ______________________
NOTE: We use your utility expenses to determine your SNAP benefit amount. Usually, you may choose to use a utility standard or
your actual verified utility costs only at application. Once you have chosen between the standard and actual costs, you may not switch
to the other option until your next application. Contact your worker if you need more information.
SECTION 6 - DID YOUR DEPENDENT CARE COSTS CHANGE?
Dependent care costs are payments for the care of a child or an adult aged 60 or older and/or an individual with a disability to allow
someone in the household to work, look for work, or attend school or a training course. You are allowed, but not required, to report
changes in dependent care costs.
Name of Person Who Pays this Cost
Name of Person Who is Paid
New Amount Paid
How Often Paid?
$
SECTION 7 - SNAP HOUSEHOLDS ONLY - DID THE MEDICAL EXPENSES OF AGED AND/OR
INDIVIDUALS WITH DISABILITIES INCLUDED IN THE HOUSEHOLD CHANGE?
We can deduct the medical expenses of household members who are age 60 or older or who are receiving disability benefits including:
1) social security disability, 2) SSI, 3) VA benefits paid for a permanent and total disability, or 4) permanent disability payments from
a state or federal agency. (This includes charges for doctors, dentists, hospitals, Medicare, Medipak, other health insurance,
prescription drugs*, dentures, hearing aids, glasses, attendants or nurses, transportation for medical care, and many other medical
costs.) You are allowed, but not required, to report changes in medical expenses. If you choose to report a change in medical
expenses, you must send proof of the new amount.
Name of Person With Medical Costs
Type of Expense
New Amount
Paid
How Often is this
Payment Due?
* You may wish to provide a printout from the drugstore or a list of the prescription drugs you take each month.
SECTION 8 - DID SOMEONE START PAYING CHILD SUPPORT?
Report here if you or anyone else in your household began paying child support to someone living outside your home.
Who pays child support?
How much do they pay? $
To whom is support paid? Name _______________________________ How often do they pay? ________________
Address_________________________________
_________________________________
Telephone_________________________________
Are the child support payments court ordered?
YES
NO
SECTION 9 – HEALTH COVERAGE
Is anyone in the household enrolled in health coverage? YES
NO
If Yes, please state who has health coverage and the type of
coverage that they have. (Examples: Employer insurance, TRICARE, Medicare)
Use a sheet of paper if you need more room to report.
Person’s name:
Coverage Type:
Person’s name:
Coverage Type:
Person’s name:
Coverage Type:
DCO-234 (rev. 12/18) 4
SOCIAL SECURITY NUMBERS (SSNs)
Households must provide or apply for an SSN for each household member who will be participating in Medicaid, Supplemental
Nutrition Assistance Program, and TEA. Failure or refusal to provide for or to supply a social security number will result in that
individual's disqualification.
PENALTY WARNINGS
Information on this form may be verified by Federal, State and
local officials through computer matching. If any information is
found to be incorrect, TEA, Medicaid, and/or SNAP benefits may
be denied or stopped. Also, the applicant/recipient may be
subject to criminal prosecution for knowingly providing incorrect
information.
If you receive Medicaid and intentionally withhold information or
misrepresent facts, you may be referred for criminal prosecution.
For TEA, your family may be disqualified from the program for 1
year after the first violation, 2 years after the second violation,
and permanently for more than two violations.
Any member of your household found to have intentionally
broken SNAP rules will be disqualified from the Supplemental
Nutrition Assistance Program for 1 year after the first violation, 2
years after the second violation and permanently after the third
violation. The SNAP rules are:
Do not give false information or withhold information in order to get or
to continue getting 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,
beer, or household supplies.
Do not trade or sell SNAP benefits or allow unauthorized use of
electronic benefit transfer (EBT) cards.
Do not use someone else's EBT card for your household's benefit.
Additional SNAP Violation Penalties:
A court of law can ban anyone who intentionally breaks
SNAP rules from getting SNAP benefits for an additional 18
m
onths and can impose fines of up to $25,000, or send the
violator to jail for up to 20 years or both.
Any member of your household found to have made a
fraudulent statement or representation about their identity or
residence in order to get SNAP benefits in two locations in
the same month may be disqualified for 10 years.
No individual will be eligible to receive SNAP benefits as
long as he or she is classified as a fleeing felon and/or
a
pa
role or probation violator.
The following individuals are permanently disqualified from
receiving SNAP benefits:
Violators found guilty in a court of law of buying or selling
firearms, ammunition, explosives, or controlled substances in
exchange for SNAP benefits.
Violators found guilty in a court of law of trafficking SNAP
benefits in excess of $500.
Individuals who were found guilty of or who pled guilty or
nolo contendere (no contest) to any state or federal offens
e
c
lassified as a felony by the law or jurisdiction involved, a
nd
w
hich has as an element of the offense the distribution or
manufacture of a controlled substance.
YOUR SIGNATURE
I understand the penalty for hiding or giving false information. I also understand I must repay extra SNAP, TEA, or Medicaid
benefits that I receive because I did not fully report changes in my household. I agree to provide verification of any reported changes
if I am asked to do so. As necessary to verify information contained in this report, I hereby authorize my employer(s), any banks,
savings and loans, lending institutions, etc., and/or Federal or State agencies to release information about me or my circumstances to
the Division of County Operations. I certify under penalty of perjury that my answers on this form are correct and complete to the
best of my knowledge and that all household members are either U.S. citizens or aliens with legal immigration status.
Do you expect the changes that you reported will remain the same next month? YES
NO
If you answered no, please explain: _____________________________________________________________________
∗
SIGN HERE _____________________________________________ Today's Date ___________________________
IF YOUR BENEFITS CHANGE
We will use the information you provided on this form to determine if your household's benefits must change. If we must change your
benefits, we will send you a notice explaining the action. If you do not agree with our decision, you may have a hearing to appeal the
decision. Your notice will tell you how to ask for a hearing.
CIVIL RIGHTS
The Arkansas Department of Human Services will not discriminate against any individual or group because of race, sex, religion, age,
national origin, color, marital status, disability, political affiliation, or veteran status. In accordance with Federal law and U.S.
Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex,
age, religion, political beliefs, or disability. To file a complaint of discrimination in the Supplemental Nutrition Assistance Program,
write: USDA, Director, Office of Civil Rights, Room, 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington,
D.C. 20250-9410. (Telephone and TDD for Hearing Impaired - 1-202-720-5964)
VOTER REGISTRATION
Would you like to register to vote or change your voter registration address? YES
NO
If you marked yes, please complete the attached Voter Registration application and return it to your local DHS office or mail to the
address listed on the form.
PLEASE PRINT AND USE BLACK INK TO COMPLETE
ARKANSAS VOTER REGISTRATION APPLICATION
Rev. 12-17-15
Check all that apply:
____ This is a new registration.
____ This is a name change.
____ This is an address change.
____ This is a party change.
Ofce Use Only
Assigned ID
1
2
3
4
7
5
6
Mr.
Mrs.
Miss
Ms.
Last Name
Jr. Sr.
II. III. IV.
First Name Middle Name
Address Where You Live (See Section “C” Below)
(Rural addresses must draw map.)
Apt. or Lot#
City/Town County
ZIP Code
State
Address Where You Receive Mail If Different From Above
Apt. or Lot#
City/Town County
ZIP Code
State
Date of Birth _________/_________/_________
Month Day Year
Home & Work Phone Numbers (Optional)
(H) (W)
Party Afliation (Optional)
E-mail Address (Optional)
8
Have you ever voted in a federal election in this State? c Yes c 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 ne of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.
9
10
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#:_____________________
ID Number - Check the applicable box and provide the appropriate number.
c
Arkansas Driver’s license number
_ ___________________________________
c If you do not have a driver’s license provide the last 4 digits of social
security number __________________________________________
c I have neither a driver’s license nor social security number.
(A) Are you a citizen of the United States of America and an Arkansas resident?
c Yes c No
(B) Will you be eighteen (18) years of age or older on or before election day?
c Yes c No
(C)
Are you presently adjudged mentally incompetent by a court of competent jurisdiction
?
c Yes c No
(D) Have you ever been convicted of a felony without your sentence having been
discharged or pardoned?
c Yes c 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.
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 Ofcial Use Only)
A
Mr.
Mrs.
Miss
Ms.
Previous Last Name
Jr. Sr.
II. III. IV.
First Name Middle Name
Date of Birth
_________/_________/_________
Month Day Year
B
Previous House Number and Street Name
Apt. or Lot#
City/Town County
ZIP Code
State
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.
C
• 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.
D
IDENTIFICATION REQUIREMENTS
IMPORTANT:
If your voter registration application
form is submitted by mail and you are registering
for the rst time, and you do not have a valid
Arkansas driver’s license number or social security
number, in order to avoid the additional identication
requirements upon voting for the rst time you
must submit with the mailed registration form: (a) a
current and valid photo identication; or (b) a copy
of a current utility bill, bank statement, government
check, paycheck, or other government document
that shows your name and address.
Example
• Grocery
Store
• Public School
X
NORTH
Woodchuck Road
Route #2
First
Class
Postage
Required
From:
________________________________
________________________________
________________________________
Arkansas Secretary of State
ATTN: Voter Registration
P.O. BOX 8111
Little Rock, Arkansas 72203-8111
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 qualied and the information on your form is complete, you will be notied 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 conrmation
of this application within two weeks.
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Completed 12 February 2021

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