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What sections of the application do I need (State of Arkansas)

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1
DCO-0004 (R. 08/20)
Arkansas Department of Human Services
Application for SNAP, Health Care, and TEA/RCA Benefits
This is a combined application for food, medical, and cash assistance. You can answer only the questions related to
the program(s) for which you are applying. Please answer all questions if you are applying for all programs. A friend,
relative, or anyone that you wish, may help you complete this application.
What sections of the application do I need to complete?
To apply for SNAP:
Check the box below and complete all
the sections marked for SNAP, even if
other programs are listed along with it.
If the question states that it is not
required for SNAP, you are not required
to complete that section.
To apply for Health Care:
Check the box below and complete
all the sections marked for Health Care, even
if other programs are listed along with it.
If the question states that it is not required
for Health Care, you are not required to
complete that section.
To apply for TEA or RCA:
Check the box below and complete all the
sections marked for TEA/RCA, even if
other programs are listed along with it.
If the question states that it is not
required for TEA/RCA, you are not
required to complete that section.
SNAP
Supplemental Nutrition
Assistance Program (SNAP):
Monthly benefits to help pay for
groceries.
Health Care
Free or low-cost insurance from
Medicaid to help pay for doctor visits,
hospital stays, prescription medicines,
lab tests, x-rays, and more.
TEA/RCA
Transitional Employment Assistance (TEA):
cash assistance to help families with children
under 18 to become more independent.
Refugee Cash Assistance (RCA):
cash assistance to help individuals who
have recently entered the US with a certain
immigration status.
Please select below if you would like to apply for any of these specific types of Health Care assistance.
(not all-inclusive)
TEFRA
Autism Services
ARChoices
PACE (Programs of All-
Inclusive Care for the Elderly)
want to receive home and community-based services safely in their home instead. (Must live in an area
Assisted Living Assistance
Nursing Facility
Assistance
Community Employment
Support (DDS Waver)
Provides services for people with developmental disabilities so they can participate as active members in
their communities.
Medically Needy
Spend-Down
assistance but who have high medical bills within a 3-month period and meet the program
Medicare Savings
Program
Medicare premiums, deductibles, and co-insurance for low-income individuals, to paying only a portion
2
DCO-0004 (R. 08/20)
Language Support
If you do not speak English, have a hearing impairment, or have a disability, let us know how we can help you (an interpreter,
sign language, TDD/TTY phone number we should call, assistive listening device, etc.)
or you may provide your own support.
You can also call Client Assistance for free at 1-800-482-8988.
Si no habla inglés, tiene una discapacidad auditiva o tiene una discapacidad, háganos saber cómo podemos ayudarle (un intérprete, un lenguaje de señas,
un número de teléfono TDD / TTY al que debemos llamar, un dispositivo de asistencia auditiva, etc.) o puede traer su propio apoyo. Llame a Asistencia al
Cliente de forma gratuita al 1-800-482-8988.
What is the language that you need to read?
English
Spanish
Marshallese
Other:
In what language do you prefer for notices to be sent?
English
Spanish
Marshallese
Other:
Do you need an interpreter?
Yes
No
If yes, what language?
______________________
STEP 1
About Your Head of Household
Head of Household Full Name:
Physical Address: Unit/Apt:
City: State: ZIP:
Mailing Address (If different): Unit/Apt:
City: State: ZIP:
Preferred Phone: Alternate Phone:
Email:
Do you want to receive electronic notifications and alerts for your case? If so, check:
Phone alerts
Email alerts
Do you currently live in Arkansas?
Yes
No
Has anyone in your household received assistance in another state in the last 30 days?
Yes No
In which of the following settings do members of your household live?
Home
College Housing
Transitional Housing
Nursing Home
Homeless
Prison/Jail
Mental health facility
Drug/alcohol treatment facility
Shelter
Other
Is anyone temporarily absent from the home? (military, hospital, incarceration, school/college, etc.)
Yes
No
If yes, list the name(s) of those person(s):
Are you applying for anyone that is recently deceased?
Yes No
If yes, list their name and date of death Name: Date of death:
Does the facility where you live provide you with the majority (over 50% of three meals daily) of
your meals as part of its nutrition services?
(SNAP only)
Yes No
STEP 2
Interview Requirements
Households applying for SNAP and TEA/RCA are required to complete an interview to see if they are eligible. This interview can be in-
person, over the phone, or virtual. Only one interview is necessary when applying for both SNAP and TEA/RCA.
If you miss your scheduled appointment for an interview, we will not schedule another one unless you ask us to do so.
1. Would you prefer an in-person or telephone interview?
In-person Telephone
If a telephone interview was selected, you must provide a working
phone number. Be sure to have service or minutes available.
Phone Number (if different from above): ____________________________
3
DCO-0004 (R. 08/20)
FOR AGENCY USE ONLY
Case Number(s):
Programs Applied For
Disposition
For SNAP Only:
SNAP-------------------------------
Pended
Approved
Denied
Expedite?
TEA/RCA--------------------------
Pended
Approved
Denied
Yes
No
Health Care---------------------- Pended Approved Denied
Screen Date: LD Date:
LTSS/Nursing Facility
TEFRA/Autism
DDS Waiver
Received Date:
Screener: Disposition Date:
STEP 3 Expedited Screening (for SNAP Only)
Most SNAP applications are processed within 30 days. However, in some cases a household may be entitled to expedited services. Please
answer the questions below so we can decide if you are eligible to have your SNAP application processed sooner.
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 get from
work and money you get in the form of checks or cash. Also, you must include money that you and other members of your household have already
gotten so far this month and money that you will be getting 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 does your household pay monthly for housing and utilities?
$___________________
4. Which utilities do you pay for separate from rent or mortgage? (Check all that apply)
Electricity
Natural Gas
Water
Trash
Phone
Other
For Households with Migrant or Seasonal Farm Workers:
5. Are you or anyone in your household a migrant or seasonal farm worker?
Yes No
If so, did anyone in your household’s income recently stop?
Yes
No
6. Does anyone expect income from a new source this month?
Yes
No
If yes, how much will the income be?
$______________________
When do you expect to get it?
$______________________
Right to File:
You have the right to immediately file an application for SNAP (food assistance) so long as your name and the signature of a responsible
household member or authorized representative (see Appendix C) are provided on this page. SNAP benefit amounts are based on the
date of application among other factors. You will not be approved for benefits until the full application process is complete.
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 I may have to provide proof that shows what I've told the Department
is true. I understand that this information may affect my household’s eligibility for benefits. I also understand that I must tell the Department about any changes to
the information I gave on my application. I understand that if required, I must cooperate with the Office of Child Support Enforcement as a condition of eligibility. I
have received, reviewed, and agree to the information about my responsibilities included in this application. I certify, under penalty of perjury, that the information
I have given on this form is true and complete to the best of my knowledge.
Signature: __________________________________________________ Date: __________________________
Note: An Authorized Representative may sign this document as long as you have provided the information required in Appendix C (attached).
STEP 4
EBT Card
Any SNAP or TEA/RCA benefits you get will be put on your household’s Arkansas Electronic Benefit Transfer (EBT) card. If you have never
had an EBT card in Arkansas, one will be mailed to you once benefits have been approved. If you need to replace a lost or stolen card, you
can call the EBT Help Desk at 1-800-997-9999 or check “yes” below for assistance.
Have you ever had an EBT card in Arkansas?
Yes
No
If yes, do you need help ordering a new EBT card?
Yes
No
click to sign
signature
click to edit
4
DCO-0004 (R. 08/20)
STEP 5
About Everyone in Your Household
(Even if you are not requesting benefits for them)
EXAMPLE
Household Member
#1
(YOU)
Household Member
#2
1. First Name: Maria
Middle Name: Denae
Last Name: Johnson
2. Date of Birth: 01/23/1987
3. Gender: Female
4. Race/Ethnicity
(American Indian or Alaska Native, Asian Indian, Black or African
American, Chinese, Chicano/a, Cuban, Filipino, Guamanian or Chamorro, Japanese,
Korean, Mexican, Mexican American, Native Hawaiian, Non-Hispanic/Latino, Other
Asian, Other Pacific Islander, Puerto Rican, Samoan, Spanish Origin, Vietnamese,
Another Hispanic or Latino, or White):
Vietnamese
5. Is this person a U.S. citizen? (Immigrants may be eligible for benefits) Yes
6. Social Security Number:
(Leave blank if the person doesn’t have one or isn’t applying for benefits)
555-55-5555
7. Relationship to Head of Household: daughter
8. Which benefits is this person applying for with your
household?
(List all that apply. If none, write “N/A”)
SNAP, TEA
9. Are you or your spouse the biological or adoptive parent(s) of
this person?
No
10. Is this person active duty military, a veteran, or the spouse or
dependent child of someone who is active duty or a veteran?
If yes, which?
Yes, veteran
11. Is this person in foster care?
No
12. Was this person in Arkansas foster care and enrolled in Health
Care assistance when they turned 18 through 21?
(Health Care only)
Yes
13.
Is this person a full-time student?
No
14. Is this person enrolled in college or vocational school? Yes
If yes, name of the school/program and whether they are going
full time or part-time:
McKinley
Tech – Full
15. Is this person fleeing from felony prosecution, an outstanding
felony warrant, or jail?
(SNAP and TEA only)
Yes
16. Is this person currently pregnant or was pregnant in the last
90 days?
Yes
If this person is pregnant now, when is the baby due?
MM/DD/YY
If pregnant now, how many babies are expected during
this pregnancy? (Health Care only)
1
If this person was pregnant in the last 90 days, when did the
pregnancy end?
MM/DD/YY
Was this person enrolled in or eligible for Health Care assistance at
the time of the child’s birth? (Health Care only)
Yes, Not
sure
17. Has this person had high medical bills within the 7-month
period including the last three, the current one, and the next
three months? If so, which 3 months were they the highest?
(Health Care only)
Yes,
Oct-Dec
5
DCO-0004 (R. 08/20)
18. Does this person have any unpaid medical bills from the last 3
months?
(Health Care only)
Yes
If yes, in which of the last 3 month(s) does this person have unpaid
medical bills?
June, July
Have payment arrangements been made?
No
What was your household size in the last 3 months?
3 people
Did this person’s income change in the last 3 months?
No
If yes, when and what changed?
Feb, lost job
Did this person move out of the state in the last 3 months?
Yes
If yes, when did this person move out of the state?
June/July
Did this person’s resources change in the last 3 months?
Yes
If yes, how did they change?
New acct.
19. Did this person have health insurance through a job and lost it
in the past 3 months? (Health Care only)
Yes
If yes, when did the coverage end? (Health Care only)
12/31/2020
If yes, what is reason for the coverage ending? (Health Care only)
Laid off
20. Is this person blind, disabled, or need help with daily living
activities (such as bathing or walking)?
21. Is this person living in or planning to live in an Assisted Living
Facility?
Yes
If yes, what is the name of the nursing facility?
Fox Ridge
22. Is this person living in or planning to live in a nursing home in
the next 15 days?
Yes
If yes, what is the name of the facility?
Fox Home
23. Is this person over age 21 and have a physical disability that
would require them to live in a nursing facility but would
rather get home and community-based services?
(Assisted Living Facilities, PACE, ARChoices, etc.)
Yes
24. Is this person currently living in an Intermediate Care Facility
for the Intellectually Disabled?
No
25. Is this person currently living in a Human Development Center?
No
26. Does this person have a developmental disability and want to
get home and community-based services?
(example: DDS Waiver, Autism Waiver)
No
27. Is this person in an alcohol or drug treatment program? No
28. Has this person previously had benefits stopped for providing
false information?
(SNAP and TEA only)
No
29. Do you usually buy and make meals together? (SNAP only)
30. Is this person currently a victim of domestic violence, victim of
trafficking, migrant farmworker, seasonal farmworker, or
refugee/asylee? If so, which?
Yes, Refugee
31. Is this person under 5 years of age AND not up to date on their
immunizations?
(TEA/RCA only)
Yes
32. Is this person between ages 5-17 AND not enrolled in school
now? (TEA/RCA only)
No
Yes, blind
Yes
6
DCO-0004 (R. 08/20)
STEP 5
(continued)
About ADDITIONAL Members In Your Household
Household Member
#3
Household Member
#4
Household Member
#5
1. First Name:
Middle Name:
Last Name:
2. Date of Birth:
3. Gender:
4. Race/Ethnicity
(American Indian or Alaska Native, Asian Indian, Black or
African American, Chinese, Chicano/a, Cuban, Filipino, Guamanian or Chamorro,
Japanese, Korean, Mexican, Mexican American, Native Hawaiian, Non-
Hispanic/Latino, Other Asian, Other Pacific Islander, Puerto Rican, Samoan,
Spanish Origin, Vietnamese, Another Hispanic or Latino or White):
5. Is this person a U.S. citizen?
(Immigrants may be eligible for
benefits)
6. Social Security Number:
(Leave blank if the person doesn’t have one or isn’t applying for benefits)
7. Relationship to Head of Household:
8. Which benefits is this person applying for with your
household? (List all that apply. If none, write “N/A”)
9. Are you or your spouse the biological or adoptive
parent(s) of this person?
10. Is this person active duty military, a veteran, or the spouse
or dependent child of someone who is active duty or a
veteran?
11. Is this person in foster care?
12. Was this person in Arkansas foster care and enrolled in
Health Care assistance when they turned 18 through 21?
(Health Care only)
13. Is this person a full-time student?
14. Is this person enrolled in college or vocational school?
If yes, name of the school/program and whether they are going
full time or part-time:
15. Is this person fleeing from felony prosecution, an
outstanding felony warrant, or jail? (SNAP and TEA only)
16. Is this person currently pregnant or was pregnant in the
last 90 days?
If this person is pregnant now, when is the baby due?
If pregnant now, how many babies are expected during
this pregnancy? (Health Care only)
If this person was pregnant in the last 90 days, when did the
pregnancy end?
Was this person enrolled in or eligible for Health Care assistance
at the time of the child’s birth?
(Health Care only)
17. Has this person had high medical bills within the 7-month
period including the last three, the current one, and the
next three months? If so, which 3 months were they the
highest? (Health Care only)
7
DCO-0004 (R. 08/20)
18. Does this person have any unpaid medical bills from the
last 3 months?
(Health Care only)
If yes, in which of the last 3 month(s) does this person have unpaid
medical bills?
Have payment arrangements been made?
What was your household size in the last 3 months?
Did this person’s income change in the last 3 months?
If yes, when and what changed?
Did this person move out of the state in the last 3 months?
If yes, when did this person move out of the state?
Did this person’s resources change in the last 3 months?
If yes, how did they change?
19. Did this person have health insurance through a job and
lost it in the past 3 months?
(Health Care only)
If yes, when did the coverage end? (Health Care only)
If yes, what is reason for the coverage ending? (Health Care only)
20. Is this person blind, disabled, or need help with daily living
activities (such as bathing or walking)?
21. Is this person living in or planning to live in an Assisted
Living Facility?
If yes, what is the name of the nursing facility?
22. Is this person living in or planning to live in a nursing home
in the next 15 days?
If yes, what is the name of the facility?
23. Is this person over age 21 and have a physical disability
that would require them to live in a nursing facility but
would rather get home and community-based services?
(Assisted Living Facilities, PACE, ARChoices, etc.)
24. Is this person currently living in an Intermediate Care
Facility for the Intellectually Disabled?
25. Is this person currently living in a Human Development
Center?
26. Does this person have a developmental disability and want
to get home and community-based services?
(example: DDS Waiver, Autism Waiver)
27. Is this person in an alcohol or drug treatment program?
28. Has this person previously had benefits stopped for
providing false information? (SNAP and TEA only)
29. Do you usually buy and make meals together? (SNAP only)
30. Is this person currently a victim of domestic violence,
victim of trafficking, migrant farmworker, seasonal
farmworker, or refugee/asylee? If so, which?
31. Is this person under 5 years of age AND not up to date on
their immunizations?
(TEA/RCA only)
32. Is this person between ages 5-17 AND not enrolled in
school now? (TEA/RCA only)
8
DCO-0004 (R. 08/20)
STEP 6
Are Any Applicants in Your Household a Non-U.S. citizen?
■ Yes – complete below
■ No – (skip to step 7)
Many immigrants are eligible for benefits. Complete the immigration information for the household members who
are not U.S. citizens and are seeking benefits. We must ask Immigration Services (USCIS) to verify the status of
anyone who is seeking benefits for themselves. This may affect your eligibility for benefits and the amount of your
benefits.
Immigration Statuses
• Lawful Permanent Resident
• Employment authorization
• Refugee
• Asylee
• Parolee
• Marshall Islander
• Amerasian
• Canadian Born American Indians
• Cuban or Haitian
• Palauan
• Iraqi and Afghan Special Immigrant
• Micronesian
• Family Unity beneficiary
• Conditional Entrant
• Battered Alien or Child of a Battered Alien
• Victim of Trafficking
• Temporary Protected Status (TPS)
• Temporary Resident Status
• Under Deferred Enforced Departure (DED)
• Administrative Stay of Removal
• Noncitizen with Withholding of Removal
• Deportation or removal withheld
• Convention Against Torture protectee
• Deferred Action status
• VISA with Adjustment of Status
• Special Immigrant Juvenile Status (SIJS), including pending
applicants for SIJS
•
Undocumented
Household Member
Name
Alien #
Immigration Status
(use categories above)
Date Entered
the U.S.
(mm/dd/yy)
Immigration
Document Type
Document ID
Number
Did anyone above move to the U.S. before
August 22, 1996?
Yes No
If yes, who?
If you are a Lawful Permanent Resident (LPR),
do you have a sponsor?
Yes No
Sponsor name:
Sponsor’s address: City:
State:
ZIP:
Sponsor’s employer: Sponsor’s monthly income: $
Have you, your parents, your spouse, or your sponsor ever worked in the U.S.?
Yes
No
9
DCO-0004 (R. 08/20)
STEP 7 Tax Information (Health Care only)
1. Is anyone in your household planning to file taxes next year?
If yes, complete the section below.
Yes
No
Tax Filer Name Filing Status
Tax Dependents Claimed Who Are
Living with the Tax Flier
Tax Dependents Claimed Who Are
NOT Living with the Tax Flier
Tax Filer 1 Name:
______________
Single
Married
(Filing Jointly)
Married
(Filing Separate)
Tax Filer 2 Name:
______________
Single
Married
(Filing Jointly)
Married
(Filing Separate)
2. Is anyone in your household a tax dependent of someone NOT living with you?
If yes, complete the section below.
Yes
No
Tax Dependent name Name of Tax Filer Claiming Dependent Tax Filer Address
10
DCO-0004 (R. 08/20)
STEP 8
Does your household have any income?
■ Yes – complete below ■ No – (skip to step 9)
Who in your
household is
employed?
(Include yourself and
write full names)
Employer’s Name
(If self-employed,
write “self-employed”)
Employer’s
Address
Employer’s
Phone #
Job Start
Date
Paycheck
Amount
(Before taxes
and
deductions)
How Often
Paid?
(example: daily,
weekly, biweekly,
monthly, etc.)
What types of income does your household get other than those listed above? For example:
• Unemployment/Workers Comp
• Self-employment/Odd Jobs
• Help with Expenses
• Alimony Received
• Child Support
• Foster Care/Adoption Subsidy
• Lottery/Gambling Winnings
• Prizes/Awards
• Social Security (SSI)
• Veterans Disability
• Other VA benefit
• Net Rental/Royalty
• Social Security (Non-SSI)
• Net Farming/Fishing
• Pensions & Retirement
• Cash Gifts
Income type
Who in your household gets this?
(Full name)
Amount
(Before taxes &
deductions)
How often? (Example: daily,
weekly, every two weeks,
monthly, etc.)
Has the income for anyone in your household changed in the last 30 days?
Yes No
If yes, whose income changed? How did the income change?
11
DCO-0004 (R. 08/20)
STEP 8
(continued)
Additional Income Questions
1. Please check all that can be deducted on the household’s tax return: (Health Care only)
Alimony paid
$______________ How often: ______________________
Other deductions paid:
$______________ How often: ______________________
Student loan interest paid
$______________ How often: ______________________
If any of these are checked; please list which household members is
claiming these deductions:
Name(s):
2. Does anyone pay your household for meals or to rent a room?
Yes No
If yes, person’s full name: ______________________________________ Monthly payment: $________________
3. Does anyone in your household have an annuity?
Yes, value:
$___________
No (Skip to Step 9)
Is a beneficiary of the annuity a member of your household?
Yes No
If yes, full name(s) of beneficiaries:
What type of annuity is it?
Deferred Immediate Retirement
What kind of annuity is it?
Revocable Non-Assignable Irrevocable
On what date was the annuity established? _____/_____/________
Does the annuity provide a balloon or deferred payment?
Yes No
Which entity was the annuity purchased
through?
Financial Insurance Other/Unknown
What is the source of the annuity funds?
Annuitant Retirement Plan Other/Unknown
If funds were used to purchase the annuity, were the funds from someone in your household?
Yes No
Full name of funder:
12
DCO-0004 (R. 08/20)
STEP 9
Non-Custodial Parent Information
Does any child on this application have a parent who lives outside the home?
Yes –complete below
■ No – (skip to step 10)
As a condition of eligibility for Health Care, SNAP, and TEA, you must tell DHS if any of the children for whom you are seeking
benefits have a parent that is absent from the home. If you do not want to provide the details for the absent parent, you
may provide proof that you have good cause not to cooperate.
Would you like to claim Good Cause to not cooperate with the Office of Child Support Enforcement?
Yes
No
If yes, select the Good Cause reason(s) that apply:
You are working with an agency helping to decide whether to place the child for adoption.
Court proceedings are going on for adoption of the child.
The child was born as a result of rape or incest.
Cooperation is anticipated to result in serious physical or emotional harm to the child.
Cooperation is anticipated to result in physical or emotional harm to you; which is so serious, it reduces your ability to
care for the child adequately.
Other
Child
One
Child’s Full Name: Child’s DOB:
City and State where child was born:
Tell us about the non-custodial/absent parent (provide all information you have)
Parent’s Full Name: Nickname:
DOB: Place of Birth (city, state): SSN:
Race: Phone:
Last Known Employer: Dates of Employment:
Has paternity been established?
Yes
No
Has child support been ordered?
Yes
No
Child Support Hearing Court/District: City: State:
Date Ordered: Amount Ordered: Date last received:
Child
Two
Child’s Full Name: Child’s DOB:
City and State where child was born:
Tell us about the non-custodial/absent parent (provide all information you have)
Parent’s Full Name: Nickname:
DOB: Place of Birth (city, state): SSN:
Race: Phone:
Last Known Employer: Dates of Employment:
Has paternity been established?
Yes
No
Has child support been ordered?
Yes
No
Child Support Hearing Court/District: City: State:
Date Ordered: Amount Ordered: Date last received:
13
DCO-0004 (R. 08/20)
Child
Three
Child’s Full Name: Child’s DOB:
City and State where child was born:
Tell us about the non-custodial/absent parent (provide all information you have)
Parent’s Full Name: Nickname:
DOB: Place of Birth (city, state): SSN:
Race: Phone:
Last Known Employer: Dates of Employment:
Has paternity been established?
Yes
No
Has child support been ordered?
Yes
No
Child Support Hearing Court/District: City: State:
Date Ordered: Amount Ordered: Date last received:
Child
Four
Child’s Full Name: Child’s DOB:
City and State where child was born:
Tell us about the non-custodial/absent parent
(provide all information you have)
Parent’s Full Name: Nickname:
DOB: Place of Birth (city, state): SSN:
Race: Phone:
Last Known Employer: Dates of Employment:
Has paternity been established?
Yes
No
Has child support been ordered?
Yes
No
Child Support Hearing Court/District: City: State:
Date Ordered: Amount Ordered: Date last received:
Child
Five
Child’s Full Name: Child’s DOB:
City and State where child was born:
Tell us about the non-custodial/absent parent (provide all information you have)
Parent’s Full Name: Nickname:
DOB: Place of Birth (city, state): SSN:
Race: Phone:
Last Known Employer: Dates of Employment:
Has paternity been established?
Yes
No
Has child support been ordered?
Yes
No
Child Support Hearing Court/District: City: State:
Date Ordered: Amount Ordered: Date last received:
If you have more than 5 children with non-custodial parents, please list their information on an additional sheet.
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Step 10 About Your Household’s Resources
1. Does anyone have any financial accounts?
Yes
No
If yes, list all accounts owned/co-owned by you and anyone applying with you.
(Examples: Checking/Savings account, Banking Apps, 401K, IRA, Annuities, ABLE, Money Market, Stocks/Bonds/Mutual Funds, etc.)
Type
Account Owner(s)
Bank Name
Account Balance
Date Opened
$
$
$
$
2. Does anyone in your household have cash on hand or in the home?
If yes, who? ___________________________ How much? $______________________
Yes
No
3. Does anyone in your household have any vehicles (even if they are not registered in
that person’s name)?
If yes, are any of these vehicle(s) used by someone who is sick or disabled?
Yes
Yes
No
No
Please list below all vehicles owned/co-owned by you or anyone applying with you.
(Examples: Cars, Trucks, Boats, Motorcycles, Motor homes, ATVs, etc.)
Owner
Year
Make
Model
Amount Owed
$
$
$
4. Does anyone in your household own any other property assets?
If yes, please complete the table below for you and anyone applying with you.
Yes
No
Type
Who owns this?
Fair Market Value
Amount Owed
Date Acquired
Your Home
$
$
Land
$
$
Rental Home
$
$
RV/ATV
$
$
Boats
$
$
Machinery
$
$
Trailers
$
$
Livestock
$
$
Machinery
$
$
Other:
$
$
5. Does anyone in your household have any of the following assets? …………………
If yes, complete the table below for you and anyone applying with you.
Yes
No
Type
Who owns this?
Cash Surrender Value
Date Acquired
Life Insurance
$
Trust
$
Burial Plot
$
Burial Plan/Contract
$
If checked, name of burial plan company:
Address:
6. Has anyone in your household sold, traded, or given away assets, closed any financial
accounts in the last 3 months (SNAP only) or in the last 5 years (Health Care only)?
Yes
No
What was traded or given away? Who owned it? Who got it? Fair Market Value of item
$
S
$
$
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STEP 11 Tell us About Your Household’s Expenses
1. How much does your household pay for the following per month? See below.
(Only list the amount you pay, not including housing assistance.)
Rent/Lease: $ Mortgage: $ Utilities: $ Escrow: $
Property Taxes: $ Real Estate Taxes: $ Homeowner’s Insurance: $ Condo Fee/HOA: $
Other expense(s): $
Who pays these expenses? _________________________________________________
Amount or portion paid: ______________________ How often? __________________
2. Check all the utilities that your household pays separate from your rent or mortgage:
Electricity Natural Gas
Water Trash Phone Other: ______________
Who pays these expenses? ___________________ Amount paid? ________________ How often: __________________
3. Has anyone applying for SNAP received more than a $20 energy payment(s) in the
last 12 months?
Yes No
4. Do you pay for heating/air conditioning separately from your rent? (SNAP only)
Yes No
5. Do you pay someone for a room? (SNAP only)
Yes No
If yes, how much do you pay and when did you start paying for the room:
Amount: $___________ Date: _________
What is the residence type?
Boarding house Private Residence Other: _________
How many meals are provided by the owner each day? ________________________________
How often do you pay for the room? (weekly, monthly, etc.) ___________________________
6. Does anyone in your household get lower housing costs due to getting Section 8,
HUD, etc.?
Yes No
7. Does anyone have a minor child living outside the home?
If yes, name(s): ______________________________________________________
Yes
No
8. Does anyone in your household pay child support?
If yes, who? ________________________
How much do you pay each month? $________________
Yes No
9. Is anyone in your household legally obligated to pay child support?
Yes
No
If yes, how much are you/they ordered to pay each month?
$________________
10. Does anyone in your household pay dependent care expense?
Yes No
If yes, is this expense for childcare costs? (daycare, after school, etc.)
Yes No
Is this expense for the care of a disabled household member?
Yes No
Name of dependent: _________________________________________
How much is paid $_________________________ How often? ____________________ (daily, weekly, monthly, etc.)
Name of care provider: Provider contact information:
11. Does anyone in your household who is 60 or older or disabled pay medical bills?
Yes
No
If yes, who? _____________________________ How much is paid each month? $_____________
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STEP 14 Voter Registration Information
IF YOU DECLINE TO COMPLETE THIS SECTION, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE. The decision to
register to vote is voluntary. Choosing to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency. We keep this information confidential.
We have attached a voter registration form for you. 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. If you have additional people in your household that would like a voter
registration application, please let us know.
Would you like to register to vote today?
Yes
No
Signature: ________________________________________________ Date: _________________
STEP 12
Is Anyone Applying for Health Care?
■ Yes – complete below ■ No – (skip to step 14)
1. Have you ever filed a Supplemental Security Income (SSI) application with the Social
Security Administration (SSA)?
Yes No
If yes, when did you file your SSI application with SSA? ____________________
2. Is your SSI application still in progress?
Yes
No
3. Have you previously been denied SSI eligibility by SSA on a prior application?
Yes No
If yes, when was it filed? ___________________
If there were any changes to your medical condition to report since the last time you filed an application with SSA for SSI
benefits, please list them: __________________________________________________________
4. Is anyone in your household enrolled in health coverage now from the following?
(Check all that apply and write the person(s) name(s) next to the coverage they have.)
Medicaid:
CHIP:
Medicare: TRICARE (do not mark if Direct Care or Line of Duty):
VA Health Care Program:
Peace Corps:
Employer Insurance:
If yes, name of Health Insurance:
Policy Number:
Is this COBRA coverage?
Yes
No
Is this a retiree health plan?
Yes
No
To make it easier to determine your household’s eligibility for help Health Care assistance in future years, we may use income
data, including information from tax returns.
Yes, renew my eligibility automatically for the next:
5 years (the maximum number of years allowed)
4 years 3 years 2 years 1 year Don’t use information from tax returns to renew my coverage
STEP 13 Answer if You are Applying for Health Care for a Child
1. Do you wish to participate in TEFRA if your child is eligible?
Yes No
If yes, does the child have a disability or condition which would require care in an institution?
Yes
No
2. Has any child in your home been diagnosed with Autism?
Yes
No
If yes, list the name of the child and date of diagnosis: Name: Date:
3. Does any child in the household have a primary care physician?
Yes
No
If yes, list the name of the physician and clinic: Physician: Clinic:
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STEP 15
Read and Sign this Application
I understand I must give the Arkansas Department of Human Services complete and true information to the best
of my knowledge.
I understand that I may have to provide proof that what I've told the Department is true.
I understand I must tell the Department about any changes to the information I gave on my application. I agree
to cooperate with state or federal reviewers.
I understand I will have to repay any benefits I should not have received, even if it is the Department's error.
I understand that if I am admitted to a nursing facility based on conditional Health Care approval and my
application is denied, I, or my family, will be responsible to repay any costs I owe from living in the nursing
facility.
I will use my benefits legally and will not sell, trade, or give away my benefits online or in person.
I understand that if required, I must cooperate with the Office of Child Support Enforcement as a condition of
receiving benefits.
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 true and
correct. I understand that if differences are found between what I report and information given by the sources
listed above, my household’s eligibility for benefits may be affected.
I have received, reviewed, and agree to the information about my responsibilities included in this application.
Under penalties of perjury, I state that I have reviewed this application, and to the best of my knowledge and belief,
the answers I gave within this application are true, including household, citizenship and non-citizenship information,
and I have listed all amounts and sources of income I received and property I own.
Note: An Authorized Representative may sign this document so long as you have provided the information required
in Appendix C, attached.
Signature: ______________________________ Date: ______________________________
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Appendix A
Health Coverage from Jobs
(for Health Care applicants only)
You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach
a copy of this page for each job that offers coverage.
Tell us about the job that offers coverage. Take the Employer Coverage Tool on the next page to the employer who offers
coverage to help you answer these questions. You only need to include this page when you send in your application, not the
Employer Coverage Tool.
Employee Information
Employee name (First, Middle, Last)
Social Security Number (SSN):
Employer Information
Employer name:
Employer Identification Number (EIN):
Employer address:
Employer phone number:
City:
State:
ZIP:
Who can we contact about employee health coverage at this job?
Phone number (if different from above):
Email address:
Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue) No
If you’re in a waiting or probationary period, when can you enroll in coverage? (mm/dd/yyyy) ______________
List the names of anyone else who is eligible for coverage from this job.
Name:__________________ Name:___________________ Name:________________ Name:________________
Tell us about the health plan offered by this employer
Does the employer offer a health plan that meets the minimum value standard*? Yes No
For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if they got the maximum discount
for any tobacco cessation programs and did not get any other discounts based on wellness programs.
How much would the employee have to pay in premiums for this plan? $
How often?
Weekly Every two weeks Twice a month Once a month Quarterly Yearly
What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only
to the employee that meets the minimum value standard*(Premium should reflect the discount for wellness programs.)
How much will the employee have to pay in premiums for that plan? $
How often?
Weekly Every two weeks Twice a month Once a month Quarterly Yearly
Date of change (mm/dd/yyyy):
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Employer Coverage Tool
Use this tool to help answer questions in your Health Care application, Appendix A. That part of the application asks about any
employer health coverage that you’re eligible for (even if it’s from another person’s job like a parent or a spouse). The
information in the boxes below match the boxes in Appendix A. For example, you can use the answer to question 14 on this
page to answer question 14 on Appendix A.
Write your name and Social Security number in boxes 1, and 2 and ask the employer to fill out the rest of the form.
Complete one for each employer that offers health care coverage for which you are eligible.
Employee Information The employee needs to fill out this section.
1. Employee name: (First, Middle, Last)
2. Employee Social Security number (SSN):
Employer Information
Ask the employer for this information.
3. Employer name:
4. Employer Identification Number (EIN):
5. Employer address (the Marketplace will send notices to this address)
6. Employer phone number
7. City
8. State
9. ZIP
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)
12. Email address
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3
months?
Yes (Go to question 13a).
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee
eligible for coverage(mm/dd/yyyy)? ______________________ (Go to question 14)
No (STOP and return this form to employee)
Tell us about the health plan offered by this employer
14. Does the employer offer a health plan that covers an employee’s spouse or dependent?
Yes - Which people? Spouse Dependent(s)
No (Go to question 15)
15. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 16) No (STOP and return this form to employee)
16. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family
plans): If the employer has wellness programs, provide the premium that the employee would pay if they received the
maximum discount for any tobacco cessation programs and didn’t receive any other discounts based on wellness programs.
a. How much will the employee have to pay in premiums for this plan?
$
b. How often?
Weekly Every two weeks Twice a month Once a month Quarterly Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 17. If you don’t know,
STOP and return this form to employee.
17. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only
to the employee that meets the minimum value standard*. (Premium should reflect the discount for wellness programs.)
a. How much will the employee have to pay in premiums for that plan?
$
b. How often?
Weekly Every two weeks Twice a month Once a month Quarterly Yearly
Date of change (mm/dd/yyyy):
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Appendix B
American Indian or Alaska Native Information
American Indian or Alaska Native Family Member (AI/AN)
Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your application for
SNAP, Health Care, and TEA/RCA benefits.
Tell us about your American Indian or Alaska Native family member(s).
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian
health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the
following question to make sure your family gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach.
AI/AN Person 1
AI/AN Person 2
1. Name (First, Middle, Last)
First
Middle
First
Middle
Last
Last
2. Member of a federally recognized tribe?
Yes
If yes, tribe name:
No
Yes
If yes, tribe name:
No
3. Has this person ever gotten a service from the
Indian Health Service, a tribal health program,
Urban Indian Health program, or through a
referral from one of these programs?
Yes
No
If no, is this person eligible to get services
from the Indian Health Service, a tribal
health program, Urban Indian Health
programs, or through a referral from one of
these programs? Yes No
Yes
No
If no, is this person eligible to get
services from the Indian Health
Service, a tribal health program,
Urban Indian Health program, or
through a referral from one of these
programs? Yes No
4. Certain money received may not be counted for
Health Care or the Children’s Health Insurance
Program (CHIP). List any income (amount and
how often) reported on your application that
includes money from these sources:
• Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties
• Payments from natural resources,
farming, ranching, fishing, leases, or
royalties from land designated as Indian
trust land by the Department of Interior
(including reservations and former
reservations)
• Money from selling things that have
cultural significance
$
How often? ____________________
$
How often? _______________
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Appendix C
Consent for Authorized Representative
If you would like, you can give someone the right to act for you. This person can give and get facts for this application, take
any action needed to enroll in benefits, and take any action needed to get benefits.
Please choose which programs you would like an authorized representative for:
SNAP Health Care TEA/RCA
REPRESENTATIVE - This person can apply for benefits, provide interview assistance, get notices, report changes, and make
inquiries. Your household will be held liable for any over issuance that results from the representative providing incorrect
information.
Full Name (first, middle, last): Date of Birth:
Phone: Email:
Address: Unit: City: State: ZIP:
By signing, I certify that the individual(s) designated above is (are) allowed to act on my behalf. I understand my household will
be held liable for any over issuance that results from the authorized representative providing incorrect information. I
understand that anyone knowingly providing false information may be prosecuted under applicable federal and state statutes.
I understand that the power to act as an authorized representative is valid until I modify the authorization or notify the agency
that the representative is no longer authorized to act on my behalf, or the authorized representative informs the agency that
he or she is no longer acting in such capacity, or there is a change in the legal authority upon which the individual or
organization's authority was based.
Applicant Signature: ________________________________________________ Date: _____________________
==================================================================================================================================================================================================================
I agree to maintain, or be legally bound to maintain, the confidentiality of any information provided by the agency regarding
the client.
(If the authorized representative for Health Care is a provider, staff member, or volunteer of an organization) I affirm that I will
adhere to the regulations in 45 CFR part 431, subpart F and at 45 CFR §155.260(f), 45 CFR §447.10, as well as other relevant
State and Federal laws concerning conflicts of interest and confidentiality of information.
Authorized Representative Signature: __________________________________ Date: _____________________
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Your Rights and Responsibilities
Please read this entire section carefully to understand your rights and responsibilities when you get Health Care benefits, Transitional
Employment Assistance (TEA), or benefits from the Supplemental Nutrition Assistance Program (SNAP).
Rights and Responsibilities Across All Programs
1. You have the right to be treated courteously and with respect.
2. You have the right to apply for any public assistance program at any time.
3. You have the right to have your application processed in a timely manner.
4. You have the right not to give us any or all the information we ask for, even though that may affect our ability to process your case.
5. You have the right to be notified in writing of any changes in your benefit amount.
6. You have the right to look at your case file. If you disagree with something in your file, tell your county office worker.
7. You have the right to ask for an appeal and get an administrative hearing if a decision is not reached on your case within the appropriate time
limit or if you disagree with the decision reached.
8. No person may be denied assistance on the grounds of race, color, sex, national origin, or disability.
9. You are responsible for notifying the Department of Human Services within 10 days if your personal information changes, your income or
resources change, or if any other changes occur in your circumstances.
SNAP Rights and Responsibilities
SNAP helps people with low income and few resources get the food they need for good health. SNAP electronic benefits transfer (EBT) cards are used in
place of cash to buy food. However, most people find they must spend some cash along with their SNAP benefits to buy enough food for a month.
Your Rights
1. You have the right to ask for help from your worker to get the information you need to establish your eligibility.
2. Participation in the SNAP is not time-limited. You can continue to get SNAP if you are eligible under SNAP rules. This is true even if someone in
your home gets TEA cash assistance. If someone in your home does get TEA cash assistance, participation in SNAP not count against their TEA
time limits
3. You have the right to know the SNAP rules.
4. You have the right to know how we worked your SNAP benefit case.
Your Responsibilities
1. Penalty Warnings
If you get SNAP you must follow the rules listed below:
• DO NOT give false (wrong) information or hide information to get SNAP.
• DO NOT give false (wrong) information to help someone else get SNAP.
• DO NOT put your money or property in someone else's name in order to get SNAP benefits.
• DO NOT sell or trade or try to sell or trade your SNAP.
• DO NOT use your SNAP to buy items like alcoholic drinks or tobacco.
• DO NOT use a SNAP Electronic Benefits Transfer (EBT) card that belongs to someone else to buy food for your household.
• DO NOT use SNAP benefits or allow someone else to use these benefits if you know that the benefits have been received illegally, given
to someone other than the legal owner, or are to be used in any illegal manner.
Any member of your household who admits to breaking any of these rules or who is found guilty of breaking any of these rules may be
disqualified to get SNAP
benefits for:
• One year for the first violation
• Two years for the second violation
• Permanently for the third violation
This person may also be fined up to $25,000, sent to jail for up to 20 years, or both. They may be subject to federal prosecution. Federal
penalties may include an additional disqualification period of 18 months or, for second and subsequent felony convictions for SNAP fraud, a
mandatory jail sentence.
Additional Disqualifications
• A person found guilty in a Federal, State, or local court of trading SNAP for controlled substances (illegal drugs or prescriptions that were
not written for you) will be barred from receiving SNAP for 24 months for the first violation and permanently for the second violation.
• A person found guilty by a court of trading SNAP for firearms, ammunition, or explosives will be permanently barred from getting SNAP.
• A person who is a fleeing felon or a parole or probation violator is barred from getting SNAP while they are fleeing to avoid custody.
2. Requirement to Work
Unless they are exempt, people between the ages of 18 and 50 who get SNAP must meet the Requirement to Work. Anyone who is not exempt
must work at least 20 hours per week at a job or self-employment; or attend an approved job training course at least 20 hours per week.
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DCO-0004 (R. 08/20)
3. What Can I Buy with SNAP benefits?
A person may buy only eligible foods with their SNAP benefits. Eligible foods include, but are not limited to, plants and seeds that can be used to
grow food. You cannot buy the following items with SNAP benefits:
• Paper goods
• Cleaning products
• Household items
• Alcoholic beverages
• Tobacco products
• Vitamins, medicine, or personal care items like toothpaste
• Foods prepared to be eaten in the store
• Hot food prepared in the store to be "carried out" and eaten
TEA Rights and Responsibilities
The Transitional Employment Assistance (TEA) program is intended to help needy families with children to become more responsible for their own
support and less dependent on public assistance. Assistance from the TEA program is intended to help needy families become economically self-sufficient
by providing opportunities to get and keep employment that will sustain the family. There is a limit to the number of months you can get TEA. It is your
responsibility to work toward achieving self-sufficiency before your time-limited assistance ends.
Your Rights
1. To be advised in writing of your work requirements.
2. If personal or family problems are keeping you from going to work, your case manager may be able to refer you to an agency that may be able
to help you.
3. You may apply for an extension of your TEA cash benefits at the end of your time limit due to circumstances beyond your control, if more time
will help you to become fully independent.
Your Responsibilities
1. Meetings
Attend all meetings your case manager schedules for you.
2. Personal Responsibility Agreement
The Personal Responsibility Agreement (PRA) is an agreement stating what you will have to do for us to help you. Your case manager will go
over these responsibilities with you. If you fail to do these things, it may cause a decrease in or loss of your cash assistance payment.
• You must cooperate with Child Support Enforcement unless you have good cause, work requirements, and certain responsibilities to your
family.
• You must make sure your school-age child is going to school and that your preschooler gets their immunizations (shots).
• Fulfill all the requirements of your Personal Responsibility Agreement and Employment Plan.
3. Work Participation Activities
Adults who get TEA must complete work activities as described in their Employment Plans for a minimum number of hours per week. Allowable
activities are:
• Employment with a private or public employer
• Micro-Enterprise (Self-Employment)
• On-the-Job Training
• Job Search and Job Readiness
• Work Experience
• Community Service
• Career and Technical Education
• Providing Childcare Services for a Community Service Participant
• Education Directly Related to Employment
• Job Skills Training
• Attendance at Secondary School
Your case manager will explain each activity and the participation requirements to you.
You must give DHS true information and not withhold information for the purpose of getting TEA without following the rules.
4. Penalty Warnings
• If you do not participate in your work activities, your TEA case manager will decide if you have a good reason and whether you are
getting all the support services you need. If you do not have a good reason for not participating, your cash payment may be reduced, or
your case may be closed until you do participate.
• If you get benefits to which you or your household are not entitled because you gave false information or hid information assistance will
be subject to recovery by DHS, any assistance you get in the future may be reduced to recover this overpayment, and you may be subject
to prosecution for fraud and/or fined or imprisoned.
• DO NOT give false information or hide information in order to become eligible for benefits.
• DO NOT put your money or property in someone else’s name in order to get TEA benefits.
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DCO-0004 (R. 08/20)
5. Fraud
Fraud consists of giving false (wrong) information or withholding information for the purpose of getting assistance that a person is not entitled
to under the program rules and regulations. Committing fraud can result in criminal fines, penalties, and paying back benefits.
6. Intentional Program Violation
An Intentional Program Violation (IPV) in the TEA Program occurs when a person gives incorrect information for the purpose of falsely
maintaining the family’s eligibility for TEA. If you are found guilty of an IPV you cannot participate in the program for:
(a) the first offense, one (1) year.
(b) the second offense, two (2) years.
(c) more than two, permanently.
Health Care Rights and Responsibilities
Health Care reimburses providers for covered medical services that are provided to eligible needy individuals through the Medicaid program. Eligibility is
determined based on income, resources, Arkansas residency, and other requirements. Covered services also vary among Medicaid categories. The
Arkansas Works Program is not a perpetual federal or state right or a guaranteed entitlement program and it may be ended at any time upon appropriate
notice.
Your Rights
1. You have the right to seek job search and job training services from the Arkansas Division of Workforce Services but it is not a requirement to
receive Medicaid or the Arkansas Works Program.
2. You do not have the perpetual federal or state right or a guaranteed entitlement to Arkansas Works, and it may be ended at any time upon
appropriate notice.
3. You are giving DHS your rights to seek and get money from other health insurance, legal settlements, or other third parties.
4. You are giving the Medicaid agency rights to pursue and get medical support from a spouse or parent.
Your Responsibilities
1. General Responsibilities
• You have the responsibility to notify the Department of Human Services of any changes of household members who get additional
income, acquire, or dispose of property (or if any other changes occur in your circumstances).
• You have the responsibility to give as much of the needed information as you can about your circumstances.
• You have the responsibility to fully complete forms with true information to the best of your knowledge.
• If receiving Healthcare in a nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or under a
home/community-based waiver, you have the responsibility to have the amount of health care benefits that DHS paid on your behalf to
be recovered from your estate or grantee of a beneficiary deed after your death.
• You have the responsibility to cooperate with the Office of Child Support Enforcement (OCSE) in establishing paternity and getting
medical support for each child who has a parent absent from the home if the program you have applied for asks you to do so.
2. Penalty Warnings
If you get Health Care benefits, you must follow the rules listed below:
• DO NOT give false information or hide information in order to become eligible for benefits.
• DO NOT put your money or property in someone else’s name in order to get Health Care benefits.
• If you get benefits to which you or your household are not entitled because you gave false information or hid information, assistance will
be subject to recovery by DHS, any assistance you get in the future may be reduced to recover this overpayment, and you may be subject
to prosecution for fraud, fined or imprisoned.
Department Responsibilities
The U.S. Department of Agriculture prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or
retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
The Arkansas Department of Workforce Services and the Arkansas Department of Human Services 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.
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.
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline
Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State);
found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
25
DCO-0004 (R. 08/20)
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at:
http://www.ascr.usdRIgha.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all 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:
• Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C.
20250-9410
• Fax: (202) 690-7442; or
• Email: program.intake@usda.gov.
To file a complaint of discrimination regarding a program receiving federal financial assistance through the U.S. Department of Health and Human Services
(HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or
(800)537-7697 (TTY).
Under the Department of Human Services (DHS) policy, Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national
origin, or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call the Department of Human Services Office of Employee
Relations/Office of Equal Opportunity at 501-682-6003.
You may also file a complaint of discrimination by contacting the DHS Office of Employee Relations/Office of Equal Opportunity, P.O. Box 1437 – Slot N250
Little Rock, AR 72203-1437 or call (501) 682-6003 or fax (501) 682-8926.
Privacy Notice
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.
Important Estate Recovery Notice
If you receive Health Care assistance in a nursing facility, ICF/IID facility, or under a home and community-based waiver program, the total amount of the
Health Care benefits paid on your behalf will be owed to DHS and may be recovered from your estate or from the grantee of a beneficiary deed after your
death. Your estate is the property you own at the time of your death. DHS will not make a claim against your estate while you are living. DHS will not
make claim against your estate after your death if your spouse is still living or if you have dependent minor children under age 21 or blind or have children
with disabilities. DHS will collect the debt, if any, by filing a claim in your estate. Collection may not be made if it is not cost-effective to DHS or if your
heirs apply and are granted a hardship waiver after your death. A hardship may exist if the estate property is the only source of income for your heirs, if
that income is limited, or if there are other compelling circumstances.
Quality Assurance
Your case may be selected for a Quality Assurance (QA) review. If so, the QA worker will check your case to see if you have given us the correct
information. They will also check to make sure the DHS county office processed your case correctly. If your case is selected for a QA review, the QA worker
will contact you for an interview. You are required to give information to prove your statements are true and correct. The QA worker may contact your
employer, your bank, other agencies, your landlord, etc. for information. If you do not cooperate during a QA review, your SNAP case will close. You will
not be eligible to get SNAP benefits until you cooperate with QA or until February of the following year, whichever comes first.
Your Right to Appeal
If you think that DHS has made a mistake, you can appeal its decision. To appeal means to tell someone at DHS that you think the action was incorrect and
that you want a fair review of the action. You can be represented in the process by someone other than yourself.
You can request an appeal in the following ways:
• In person: Talk to staff of any county DHS office.
• By phone: You can call the Office of Appeals and Hearings at 501-682-8622 or you may call your local county office.
• By email: DHS.Appeals@dhs.arkansas.gov
• By mail: Arkansas Department of Human Services
Appeals and Hearings Section
Slot N401
P.O. Box 1437
Little Rock, AR 72203-1437
26
DCO-0004 (R. 08/20)
OUR MISSION:
Together we improve the quality of life of all Arkansas by protecting
the vulnerable, fostering independence, and promoting better health.
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. 11/20)
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.
,I\RXDUHTXDOLÀHGDQGWKHLQIRUPDWLRQRQ\RXUIRUPLVFRPSOHWH\RXZLOOEHQRWLÀHGRI\RXU
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
&RQWDFW\RXU&RXQW\&OHUNLI\RXKDYHQRWUHFHLYHGFRQÀUPDWLRQ
of this application within two weeks.
DHS County Office Mailing Addresses
County Address City Zip County Address City Zip County Address City Zip
Arkansas PO Box 1008 Stuttgart 72160 Grant PO Box 158 Sheridan 72150 Phillips PO Box 277
Ashley PO Box 190 Hamburg 71646 Greene 809 Goldsmith Rd Paragould 72450 Pike PO Box 200
Helena 72342
Murfreesboro 71958
Baxter PO Box 408 Mt. Home 72654 Hempstead 116 N. Laurel Hope 71802 Poinsett PO Box 526 Harrisburg 72432
Benton
900 SE 13
th
Court
Bentonville 72712 Hot Spring 2505 Pine Bluff St Malvern 72104 Polk PO Box 1808 Mena 71953
Boone PO Box 1096 Harrison 72602 Howard PO Box 1740 Nashville 71852 Pope 701 N Denver Russellville 72801
Bradley PO Box 5 09 Warren 71671
Independence
100 Weaver Ave Batesville 72501 Prairie PO Box 356 DeValls Bluff 72041
Calhoun PO Box 1068 Hampton 71744 Izard PO Box 65 Melbourne 72556
Pulaski
Jax.
PO Box 626 Jacksonville 72078
Carroll PO Box 425 Berryville 72616 Jackson PO Box 610 Pulaski No. PO Box 5791 N. Little Rock 72119
Chicot PO Box 71 Lake Village 71653 Jefferson PO Box 5670
Newport 72112
Pine Bluff 71611 Pulaski So. PO Box 2620 Little Rock 72203
Clark PO Box 969 Arkadelphia 71923 Johnson PO Box 1636 Clarksville 72830
Pulaski
Sw.
PO Box 8916 Little Rock 72219
Clay PO Box 366 Piggott 72454 Lafayette 2612 Spruce St. Lewisville 71845 Randolph 1408 Pace Rd Pocahontas 72455
Cleburne PO Box 1 140
Heber
Sprin
gs.
72543 Lawrence PO Box 6 9
Walnut
Rid
ge
72476 Saline PO Box 6 08 Benton 72018
Cleveland PO Box 465 Rison 71665 Lee PO Box 309 Marianna 72360 Scott PO Box 840 Waldron 72958
Columbia PO Box 1109 Magnolia 71754 Lincoln 101 W. Wiley St. Star City 71667 Searcy 106 School St Marshall 72650
Conway PO Box 228 Morrilton 72110 Little River 90 Waddell St. Ashdown 71822 Sebastian
616 Garrison
Ave
Ft. Smith 72901
Craighead PO Box 16840 Jonesboro 72403 Logan #17 W. McKeen Paris 72855 Sevier PO Box 670 DeQueen 71832
Crawford
704 Cloverleaf
Circle
Van Buren 72956 Lonoke PO Box 260 Lonoke 72086 Sharp
1467 Hwy
62/412
Cherokee
Villa
ge
72529
Crittenden
401 S. College
Blvd
W. Memphis 72301 Madison PO Box 128 Huntsville 72740
Ste. B
Cross 803 Hwy 64E Wynne 72396 Marion PO Box 447 Yellville 72687 St Francis
PO Box 899
Forrest City 72336
Dallas 1202 W . 3
rd
St. Fordyce 71742 Miller Stone
1821 E Main
Mountain
View
72560
Desha PO Box 1009 McGehee 71654 Mississippi
3809 Airport Plaza Texarkana 71854
1104 Byrum Rd. Blytheville 72315 Union
123 W 18
th
St.
El Dorado
71730
Drew PO Box 13 50 Monticello 71657 Monroe
301½ N New
Orleans
Brinkley 72021
Clinton 72031
Faulkner 1000 East Conway 72032 Montgomery PO Box 445 Mount Ida 71957
Van Buren
449 In
gram
Street
Washington
4044 Frontage Fayetteville 72703
Siebenmorgan
Road
Nevada PO Box 292 Prescott 71857 White
608 Rodgers
Drive
Searcy 72143
Franklin
800 W
Commercial
Ozark
72949 Newton PO Box 452 Jasper 72641 Woodruff PO Box 493 Augusta 72006
Fulton
PO Box 650 Salem
72576
Ouachita PO Box 718 Camden 71711 Yell PO Box 277 Danville 72833
Garland 115 Stover Lane Hot Springs 71913 Perry 213 Hou ston Ave P erryville 72126
*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 North: 72046 (England), 72113, 72114, 72115, 72116 (Shared with Jax), 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),72016,72053, 72126,72135,72201,72201,72202,72203,72205,72207,72212,72223,72227
Pulaski Southwest: 72002, 72065, 72103, 72164, 72208, 72209, 72210, 72211, 72164, 72180, 72183, 72206 (Shared with South)
DCO-0137 (R. 11/20)
OUR MISSION:
Together we improve the quality of life of all Arkansas by protecting
the vulnerable, fostering independence, and promoting better health.
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