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Trafficking SNAP benefits in excess of 500 – a permanent disqualification.Intentional Program ViolationsTEA ProgramPeople who participate in TEA must follow these rules:If you give any information that is false or misleading or if you withhold or conceal facts for the purpose ofestablishing or maintaining your family's eligibility for TEA, you may be found guilty of committing an intentionalprogram violation (IPV) by an Administrative Hearing or through a court of law.If you plead guilty or nolo contendere (no contest) or are found guilty of an IPV, your family will be ineligible forTEA for one year for the first offense, two years for the second offense and permanently for any subsequentoffense. In addition, your family will remain ineligible to receive TEA benefits until the resulting overpayment isrepaid to the State.If you are found guilty of giving false information about your residence in order to receive TANF assistance in twoor more states at the same time, your family will be ineligible for TEA assistance for a minimum of ten yearsbeginning with the date of conviction. (The TEA Program is Arkansas' TANF Program.)Did you know that if you are eligible for SNAP or TEA, you may be eligible for thefollowing programs? Housing assistance through HUD. Visit www.hud.gov for more information. Assistance for utility costs through the Home Energy Assistance Program (HEAP). Visit www.acaaa.org tolearn which agency serves your county. Certain Medicaid categories. Visit www.access.arkansas.gov or visit your local DHS county office to apply forMedicaid. Help with your telephone service through Lifeline and Link Up or visit www.lifelinesupport.org to apply. Askyour current telephone provider for more information. Free or reduced tax preparation service through certain companies. Contact your tax preparer to see if theyoffer these services. Free or reduced legal services. Contact local legal offices for a referral in your area. Free school meals for children attending public schools. Children will be automatically enrolled through anadministrative matching program.Your Right to PrivacyThe PRIVACY ACT of 1974 requires the Department of Human Services (DHS) to tell you: (1) whether disclosure is voluntaryor mandatory; (2) how DHS will use your SSN; and, (3) the law or regulation that allows DHS to ask you for the SSN. We areauthorized to collect from your household certain information including the social security number (SSN) of each eligiblehousehold member. For the Supplemental Nutrition Assistance Program this authority is granted under the Food andNutrition Act of 2008 as amended, 7 U.S.C. 2001-2036. For both the Medicaid Program and the TEA Program, this authorityis granted under Federal laws codified at 42 U.S.C. §§ 1320b-7(a)(1) and 1320b-7(b)(2). This information may be verifiedthrough computer matching programs. We will use this information to determine program eligibility, to monitor compliancewith program rules, and for program management. This information may be disclosed to other Federal and State agenciesand to law enforcement officials. If claim arises against your household, the information on this application, including allSSNs may be provided to Federal or State officials or to private agencies for collection purposes.Wrap-4 (Rev 4/2020)

Arkansas Department of Human ServicesApplication for SNAP and TEAIF YOU NEED THIS APPLICATION IN LARGE PRINT, CONTACT YOUR DHS OFFICE.Si necesita este formulario en Español, llame al 1-800-482-8988 y pida la versión en Español.Head of Household NameDate of BirthWork PhoneMailing Address (P.O. Box, Street, Apt./Lot #)CityStateZipHome or Cell PhoneResidence Address (Street, Apt./Lot #)CityStateZipE-mail AddressWhat Services Are You Requesting? Please use blue or black ink. Supplemental Nutrition Assistance Program (SNAP) Are you currently receiving SNAP benefits? YES NOIf you believe your household needs SNAP benefits right away, complete the questions on page 2 of this form. If youdo, we can determine if you are entitled to receive SNAP benefits within 7 days. Transitional Employment Assistance (TEA) for Households with Children Under 18 Are you currently receiving TEA? YES NO Do you have a child under 18 living in your home? YES NOHave you or anyone in your household received assistance in another state?If yes, check all that apply.Do you have or have you ever had an electronic benefits transfer (EBT) card in Arkansas?If yes, do you currently have the card?1.2.3.Would you prefer an in-person interview or an interview by telephone? YES NO SNAP TEA YES NO YES NO In-person TelephoneIf you selected a telephone interview, you must provide a working phone number. Be sure tohave phone service or minutes available.4.If not English, what language do you speak at home?Do you need an interpreter? YES NOHousehold Members: List all the people who live in your home, including yourself. If needed, attach a sheet of paper listingadditional members.SocialSecurityNumberFull name(First, middle, and last)BirthdateRelationshipto youDoes thisperson buy andprepare mealsseparately?Is this person aU.S. Citizen? YES NO YES NO YES NO YES NO YES NO YES NOFederal law requires that each state provide the opportunity to register to vote with every application for public assistance. Please answer thefollowing question regarding voter registration: Would you like to register to vote or change your voter registration address?YesNoIf you marked Yes, please complete and sign the Voter Registration Application that is attached. If you marked No, submit your application to your localDHS County Office.By my signature, I authorize the Arkansas Department of Human Services (DHS) to get information from other state agencies, financial institutions,employers, federal agencies, and other sources to prove my statements are correct. I understand that if differences are found between what I report andinformation provided by the sources listed above, DHS may contact other sources for verification. I understand that this information may affect myhousehold’s eligibility for benefits. I understand that if required, I must cooperate with the Office of Child Support Enforcement as a condition ofeligibility. I certify, under penalty of perjury, that the information I have reported, as shown on this form is correct to the best of my knowledge.Signature:Date:Signature of Witness if applicant signs with an “X”:Some SNAP applicants are entitled to receive SNAP benefits within seven days (expedited service).The answers to the questions below will help us screen your household for SNAP expedited service.Answer each question for yourself and all other household members.1 DCO-215 (Rev. 4/2020)

SNAP Expedited Service for All Households:1.2.3.What is your household’s total monthly income before deductions?Deductions are amounts taken out for taxes, insurance, etc. The monthly total must includemoney that you and other household members receive from work and money received in theform of checks or cash. Also, you must include money that you and other members of yourhousehold have already received so far this month and money that you will be receiving beforethe end of the month.How much money do you and other household members currently have in cash, checkingaccounts, savings accounts, etc.?How much are your household’s monthly housing and utility costs?Regular amounts only. Do not include past due totals. SNAP Expedited Service for Households with Migrant or Seasonal Farm Workers:1.2.3.Is anyone in your household a migrant or a seasonal farm worker?Did your household’s income recently stop?Do you or anyone else in your household expect income from a new source this month?(A) If yes, how much will the income be?(B) When do you expect to receive the income?County Use OnlyExpedited:Screener:Screen Date: YES NO YES NO YES NO DATE: YES NOLD Date:Notes:Ethnicity Declaration: DHS is required to ask for racial and ethnic data on households applying for or participating inSNAP. You are not required to complete this section in order to receive assistance. If you are approved, your benefit levelwill not be affected by your decision to complete or not complete this section. DHS encourages you to answer the questions YES NObelow. Are you Hispanic or Latino? (Select only one)What is your race? (Select one or more) American Indian or AlaskanNative Pacific Islander or Native Hawaiian Black or African AsianAmerican White OtherIncome: Please check each type of income that you and anyone living in your home currently receives. Wages/Salary/Earnings Unemployment Benefits Training Allowances SSA or SSI Income Worker’s Compensation/Sick Pay Interest Income Americorp VISTA/Americorp Program Retirement/Pension/Annuity Self-employment Income Child Support/Alimony Railroad or Veteran’s benefitsResources Checking/Savings Account Trust Fund Certificate of Deposit (CD) Christmas Club Account IRA/ KEOGH/ 401K Military Allotment Income from rental propertyIncome Cash Contributions Other Campers/RV (Motor Home) Stocks/Bonds/Mutual FundsMotorcycle or ATV Mobile HomeGolf cart/ Go-cart/ Moped Burial Plots/Prepaid PlanCar/Truck/Van Real Estate (not your home)Boats/ Motors/Trailers OtherHave you or anyone in your home sold or given away any resource in the past 3 months? YES NOHave you received cash gifts, awards, or prizes of at least 3,500 or more within the last three months? YES NOHave you won the lottery totaling at least 3,500 or more? YES NOExpenses: Please check each type of expense that you or anyone else in your home pays. Rent Mortgage Payment Taxes on home Insurance on home Utilities Telephone Baby sitter or day care Medical costs Child supportFailure to report and verify any of the above listed expenses will be seen as a statement by your household that you do notwant to receive a deduction for unreported expenses.2 DCO-215 (Rev. 4/2020)

Students: Is anyone in your home currently enrolled in a college, vocational school, technical school or anyother training program beyond high school? YES NO If yes, complete the section below.1.2.3.4.Name of studentSchool or training programEnrollment statusIs the student a Work-Study Program participant? Full-time Part-time YES NOMandatory Cooperation with Child Support Enforcement: If you check YES to the questions below,you must provide the names of the parent and child(ren). Failure to provide correct information could be fraud. Ifyou have good cause not to cooperate with Child Support Enforcement, you must tell your eligibility worker. Youwill be asked to provide evidence to help determine if you have good cause.Custodial ParentNon-Custodial ParentDoes anyone in the household have a courtDoes anyone in the householdIs anyone in the householdorder for child support?have any minor children livingrequired to make child supportoutside of the home?payments?YesNoYesNoYesNoAuthorized Representative: If you want to choose someone to represent you, please complete the followinginformation. If you name an authorized representative, this person will be able to take your place at the interview and talk tothe DHS county worker on your behalf.NameMailing Address (P.O. Box, Street, Apt./Lot #)CityStateZipHome or Cell PhoneIn accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, itsAgencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminatingbased on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activityin any program or activity conducted or funded by USDA.Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hardof hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, programinformation may be made available in languages other than English.To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:http://www.ascr.usda.gov/complaint filing cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letterall of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form orletter to USDA by:(1) mail: U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410;(2) fax: (202) 690-7442; or(3) email: program.intake@usda.gov.This institution is an equal opportunity provider.Providing a Social Security Number and/or information about citizenship or immigration status is voluntary. However, anyone who fails orrefuses to provide any of this information will not be eligible to receive SNAP and/or TEA benefits. Other household members who doprovide this information may participate in SNAP and/or TEA, if the household is found to be eligible.If you are age 18 or over or 49 or under and get SNAP benefits you must also meet the Requirement To Work or the RTW rule unlessexempt from the RTW or Work Registration. The RTW rule only applies to Able Bodied Adults without Dependents or ABAWDs whoare 18 or over or 49 or under. If the work requirements of this rule are not met, then an ABAWD can only receive SNAP benefits for 3months out of a 3-year period. However, if work requirements are met, benefits may continue. Your caseworker can provide moreinformation.You can continue to receive SNAP benefits as long as you are eligible under Program rules. This is true even if someone in your homereceives TEA/Works Pays cash assistance. If someone in your home does receive TEA/Works Pays cash assistance, participation inSNAP will not count against their TEA/Works Pays time limits.Providing Information - You must declare Social Security Numbers for everyone who will receive benefits. Bringing items such as yourmost recent paycheck stubs, award letters, and bank statements to your interview may speed up the application process. During theinterview, the DHS worker will tell you if you must provide any additional information.3 DCO-215 (Rev. 4/2020)

DHS County Office Mailing fordCrittendenCross100 Court SquarePO Box 1008PO Box 190PO Box 408900 SE 13th CourtPO Box 1096PO Box 509PO Box 1068PO Box 425PO Box 71PO Box 969PO Box 366PO Box 1140PO Box 465PO Box 1109PO Box 228PO Box 16840704 Cloverleaf Circle401 S. College Blvd803 E. Hwy 64DeWittStuttgartHamburgMt. HomeBentonvilleHarrisonWarrenHamptonBerryvilleLake VillageArkadelphiaPiggottHeber Springs.RisonMagnoliaMorriltonJonesboroVan BurenW. 567230172396GrantGreeneHempsteadHot onLafayetteLawrenceLeeLincolnLittle RiverLogan-1Logan-2LonokeMadisonMarionPO Box 158809 Goldsmith Road116 N. Laurel2505 Pine Bluff St.PO Box 1740100 Weaver AvePO Box 65PO Box 610PO Box 5670PO Box 16362612 Spruce St.PO Box 69PO Box 309101 W. Wiley St.90 Waddell St.#17 W. McKeen398 E. 2nd St.PO Box 260PO Box 128PO Box MelbourneNewportPine BluffClarksvilleLewisvilleWalnut RidgeMariannaStar ulaski EastPulaski Jax.Pulaski No.Pulaski So.Pulaski 02 W. 3rd St.PO Box 1009PO Box 13501000 E.Siebenmorgan800 W CommercialPO Box 650115 Stover 2032MillerMississippi 1Mississippi 2Monroe-13809 Airport Plaza1104 Byrum Rd.437 S Country ClubPO Box 237072029St FrancisStoneUnionVan enaRussellvilleDeValls BluffLittle RockJacksonvilleN. Little RockLittle RockLittle RockPocahontasBentonWaldronMarshallFt. SmithDeQueenCherokeeVillageForrest CityMountain ViewEl 9017183275229DallasDeshaDrewFaulknerPO Box 718213 Houston Ave.PO Box 277PO Box 200PO Box 526P.O. Box 1808701 N. DenverPO Box 356PO Box 8083PO Box 626PO Box 5791PO Box 2620PO Box 89161408 Pace Rd.1603 Edison Ave.PO Box 840106 School St.616 GarrisonPO Box 6701467 Hwy 62/412Ste. BPO Box 8991821 E Main123 W. 18th St.449 Ingram St.OzarkSalemHot on301½ N New OrleansPO Box 445PO Box 292PO Box 452BrinkleyMt. teWoodruffYell4044 Frontage608 Rodgers DrivePO Box 493PO Box ressCityCityFold in half and tape ends together.Use the addresses above to mail your application to your local DHS County OfficeReturn AddressPlaceStampHereZip72336725607173072031

Each adult household member must complete the Drug Assessment questionnaire before TEA and/or Work Payseligibility can be determined.State of ArkansasTANFDRUG ASSESSMENT TOOLWORKFORCESERVICESParticipant’sName(Please print)Case #Effective January 1, 2016, in accordance with Act 1205 of 2015, all adult (above 18) TANF applicants/recipients who areotherwise eligible for TANF assistance are required to be assessed for illegal use of a controlled substance. Iftheapplicant/recipient is suspected of illegal drug use, he/she will have to undergo a drug test and potentially a substanceabuse treatment. If the applicant/recipient fails to comply with any of these requirements, the TANF case will bedenied/closed or the case will be approved with a protective payee in place.Illegal use of a controlled substance (illegal drug) means: The use of a drug that is against the law, orThe use of a prescription drug which is a controlled substance that is not prescribed for you.Return DateEach person age 18 or older in your household case mustanswer the following questions.SIGN AND DATE THIS FORMI understand the drug assessment procedures as detailed in this form and will answer each question listed belowtruthfully.Applicant’sSignatureDateANSWER EACH OF THE FOLLOWING QUESTIONS YESYES NO In the past 30 days have you used any illegal drugs?NO In the past 30 days have you lost or been denied a job due to current illegal drug use?IMPORTANT INFORMATION FOR YOUIf you do not fill out this form and return it to DHS by the return date above, your application will be denied.If you are a recipient, your case will be closed. We will send you a separate notice if we take this action. While getting cash assistance, adult household members may have to complete a drug test if there is reasonablecause to believe they are using illegal drugs.If you test positive for illegal drugs, you must cooperate with drug testing requirements and your Plan of Actionor your case will be denied/closed or processed with a protective payee in place.ADWS and DHS are Equal Opportunity Providers / Employers Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI &VII),andthe Americanswith Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of1975, 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 adisability to take part in a program, service or activity. For example, this means if necessary, the Department must provide signlanguage interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that theDepartment will take any other reasonable action that allows you to take part in and understand a program or activity, includingmak

A Social Security Number (SSN) or proof of application for an SSN for each household member applying for benefits. Documentation of legal alien status for each non-citizen applying for benefits. Proof of identity for the applicant. Proof of residence. Proof of all income.