Arkids Application PDF Details

The Arkids Application is a new application for Arkansas families that provides information on available state and local resources. The app includes an interactive map of Arkansas with location-based services, directories of state and local services, and a newsfeed featuring announcements from state agencies. According to the Governor's office, the application was designed to "provide one-stop access to information about government programs and services for families." The Arkids app is available for free download in the App Store and Google Play. Families can also find information about the app at arkids.gov.

We've gathered some useful information about the arkids application. This site will give you information about the form's length, completion time, and the parts you'll be needed to fill.

QuestionAnswer
Form NameArkids Application
Form Length4 pages
Fillable?Yes
Fillable fields170
Avg. time to fill out35 min 4 sec
Other namesforms arkids online, forms arkids, arkids in application, arkids health insurance application printable

Form Preview Example

HOUSEHOLD HEALTH

COVERAGE APPLICATION

Frequently Asked Questions

What is the fastest way to apply for coverage?

The fastest way to apply for coverage is to apply online at: https://access.arkansas.gov/

What services can I apply for with this application?

You can apply for Medicaid, ARKids First or the Arkansas Works Program.

If you are not eligible for any of the above coverage, your information will be transferred to the Federally Facilitated Health Insurance Marketplace to determine your eligibility for tax credits to help pay for a Qualified Health Plan.

Who can use this application?

Use this application to apply for you or anyone in your family.

Apply even if you or your child already has health coverage. You could be eligible for lower cost or free coverage.

Families that include immigrants can apply. You can apply for your children even if you are not eligible for coverage. Applying won’t affect your immigration status or chances of becoming a permanent resident or citizen.

If someone is helping you fill out this application, you may need to complete a DCO-153, Consent for an Authorized Representative.

What will I need to apply?

Your Social Security number (or document number if you are a legal immigrant)

Employer and income information (examples: from recent paystubs, W-2 forms, or wage and tax statements)

Information about any job related health insurance available to your family

Policy numbers for any current health insurance

Why do you need my Social Security number, employer, and income information?

We ask about income and other information to let you know what coverage you qualify for and if you can get help paying for it. We’ll keep all the information you provide private and secure as required by law. To view the Privacy Act Statement go to: https://access.arkansas.gov/.

What if I need help with my application?

You can contact the Help Center at 1-855-372-1084 or contact your local DHS county office. En Español: Llame a nuestro centro de ayuda gratis al 1-855-372-1084.

Why is there a Voter Registration application included?

A Voter Registration packet is included with this application to provide an opportunity for

you to register to vote or change your voter registration address. By applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

DCO-152 (09/18)

Page 1 of 8

Step 1: Tell Us About Yourself

(We need one adult in the family to be the contact person for your application.)

1. First Name, Middle Name, Last Name & Suffix

2. Home Address

 

 

 

 

 

 

3. Apartment or Suite Number

 

 

 

 

 

 

 

 

 

 

 

 

4. City

 

 

5. State

6. ZIP Code

 

7. County

 

 

 

 

 

 

 

 

 

 

 

8. Mailing Address (If different from home address)

 

 

 

 

 

9. Apartment or Suite Number

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

City

 

 

11. State

12. ZIP Code

 

13. County

 

 

 

 

 

 

 

 

 

 

 

 

14. Phone Number

 

 

 

 

15. Other Phone Number

 

 

 

 

 

 

 

 

 

 

 

16.

Do you live in the State of Arkansas?

Yes

No

17. If you are currently out-of-state, do you intend to return to Arkansas?

Yes

No

 

 

 

Email Address: Providing a valid email address will allow us to process your application and provide you with notice updates more efficiently.

 

Providing an email address will allow you to receive information regarding your health coverage in real time through your email account.

 

18.

Email Address:

 

 

 

 

19. I do not want to provide an email address at this time.

 

 

 

 

 

 

 

 

 

20.

Preferred spoken or written language (if not English)

 

 

 

 

 

Step 2: Tell Us About Your Family

Who do you need to include on this application?

List all the people who live in your home, including yourself. If you file taxes, we need to know about everyone on your tax return. This includes your tax dependents that do not live in your home. (You don’t need to file taxes to be eligible for health coverage.)

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure that everyone receives the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than two people in your family, you will need to fill out a form DCO-152C, Additional Household Member, for each additional member of your household and attach the form(s) to this application. You don’t need to provide immigration status or a Social Security Number (SSN) for family members who do not need health coverage. We will keep all the information you provide private and secure as required by law. We will only use your personal information to check if you are eligible for health coverage.

Please proceed to Step 2, Person 1 on the following page.

NEED HELP WITH YOUR APPLICATION? Call us at 1-855-372-1084. Para obtener una copia de este formulario en Español, llame 1-855-372- 1084. If you need help in a language other than English, call 1-855-372-1084 and tell the customer service representative the language you need. We will get you help at no cost to you.

DCO-152 (09/18)

Page 2 of 8

Step 2: Person 1

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 2 for more information about who to include. If you don’t file a tax return, remember to still add family members who live with you.

1.

First Name, Middle Name, Last Name & Suffix

2. Relationship to you?

3. Sex

 

 

 

 

 

SELF

 

Male

 

Female

 

 

 

 

 

 

4. Date of Birth (mm/dd/yyyy)

5. If you are under 18, are you emancipated?

 

Yes

 

No

 

 

If Yes, how were you emancipated?

Court Order

 

Common Law

 

 

 

 

 

 

 

6.

Social Security Number (SSN) _ _ _ - _ _ - _ _ _ _

 

 

 

 

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit ssa.gov. TTY users should call 1-800-325-0778.

7. Do you currently have health coverage and want to continue with the same coverage?

 

 

Yes

No

If No, would you like to apply for coverage?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITIZENSHIP STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Are you a U.S. citizen or U.S. national?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

Are you a citizen of the Marshall Islands, Federated States of Micronesia or Palau?

Yes

No

9. If you are not a U.S. citizen or U.S national, do you have eligible immigration status?

 

 

 

 

 

 

 

Yes Enter your document type and ID number below.

 

 

No

 

 

 

 

 

 

a.

Immigration document type:

 

 

 

 

 

 

 

 

Alien #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Document ID number:

 

 

 

 

 

 

 

 

 

_ Expiration date of document

 

 

 

c. Have you lived in the U.S. since 1996?

 

Yes

 

No

 

Date of entry into U.S.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

d. Are you or your spouse or parent a veteran

or an active duty member of the U.S. military?

 

 

 

10.

If Hispanic/Latino, what is your ethnicity and race? (OPTIONAL – Check all that apply.)

 

 

 

 

 

 

 

 

 

Mexican

 

Mexican-American

Chicano/a

Puerto Rican

Cuban

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Race (OPTIONAL – Mark (X) all that apply.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race

X

Race

X

Race

 

 

 

 

 

X

Race

 

X

Race

 

X

Race

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White

 

Filipino

 

Black/African American

 

 

 

Alaskan Native

 

Hawaiian/Pacific Islander

 

Samoan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Korean

 

Japanese

 

American Indian

 

 

 

Asian Indian

 

 

Guamanian or Chamorro

 

Chinese

 

 

 

PREGNANCY STATUS

 

 

If yes, what is your expected due date?

 

 

 

 

 

 

12. Are you pregnant?

Yes

No

 

 

(mm/dd/yyyy)

 

How many babies are you expecting during this pregnancy?

 

 

If no, have you delivered a child in the last 90

 

 

 

days?

Yes

No If yes, what was the date of delivery?

 

If yes, how many babies did you deliver? _

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOSTER CARE STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Were you in foster care in Arkansas at age 18 or older?

Yes

No

 

 

 

 

 

 

If yes, were you enrolled in Medicaid when you left the Foster Care program?

Yes

No

 

 

 

 

Are you currently receiving Medicaid?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Are you the main caregiver living with and taking care of at least one child under the age of 19?

Yes

No

 

TAX FILING STATUS

15. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health coverage even if you don’t file a federal income tax return.)

YES If yes, please answer questions a through c.

 

 

 

NO If no, skip to question c.

a.

Will you file jointly with a spouse?

Yes

No

 

 

 

 

 

 

If yes, name ofspouse:

 

 

 

 

 

 

 

 

b.

Will you claim any dependents on your tax return?

 

Yes

No

 

 

 

 

If yes, list name(s) of dependents:

 

 

 

 

 

 

 

 

c.

Will you be claimed as a dependent on someone’s tax return?

 

Yes

No

 

If yes, please list the name of the tax filer:

 

 

 

 

_

 

How are you related to the tax filer?

 

 

 

 

 

 

 

 

 

DCO-152 (09/18)

Page 3 of 8

Step 2: Person 1 (Continued)

CURRENT JOB & INCOME INFORMATION:

 

 

 

Employed

 

 

 

 

 

 

 

 

 

 

 

Not Employed

 

 

 

 

 

 

 

 

 

 

 

Self Employed

 

 

 

 

 

 

 

 

 

If you are currently employed tell us about

 

Skip to Question 24.

 

 

 

 

 

 

 

 

 

 

Skip to Question 25.

 

 

 

 

 

 

 

 

 

your income. Start with question 17.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT JOB 1:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. Employer Name and Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. Employer Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. Wages/tips (before taxes) $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hourly

Weekly

Every 2 Weeks

 

Twice a Month

 

 

 

Monthly

 

Yearly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. Average hours worked each week:

 

 

 

 

 

 

 

Start date of employment

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT JOB 2: (Attach another sheet of paper to list more jobs.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Employer Name and Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. Employer Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. Wages/tips (before taxes) $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hourly

Weekly

 

 

Every 2 Weeks

 

Twice a Month

 

 

 

 

 

Monthly

 

Yearly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. Average hours worked each week:

 

 

 

 

 

 

 

Start date of employment

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. In the past year, did you:

 

Change jobs?

 

 

 

 

Start working fewer hours?

 

 

 

Stop working?

 

 

None of these?

 

 

 

 

 

 

If you stopped working what was

the date that the

job ended?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. If self-employed, answer the following questions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Name of Business:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. How much net income (profits once business expenses are paid) will you receive from this self-employment this month? $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26. OTHER INCOME THIS MONTH: Enter the amount and how often you receive that amount for all income that is not listed above.

 

 

 

 

 

 

 

 

 

NOTE: You don’t need to tell us about child support, veteran’s payments or Supplemental Security Income (SSI).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCOME

 

Amount

 

 

 

How Often

 

 

 

 

INCOME

 

 

 

Amount

 

How Often

 

 

INCOME

 

 

Amount

 

How Often

 

 

 

 

None

 

 

 

 

 

 

 

 

 

 

 

Taxable Interest

 

 

 

 

 

 

 

 

 

 

 

Tax Exempt Interest

 

 

 

 

 

 

 

 

 

 

 

Dividends

 

 

 

 

 

 

 

 

 

 

 

Foreign Income

 

 

 

 

 

 

 

 

 

 

 

Unemployment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pensions/Retirement

 

 

 

 

 

 

 

 

 

 

 

Social Security

 

 

 

 

 

 

 

 

 

 

 

Net Farming/Fishing

 

 

 

 

 

 

 

 

 

 

 

Retirement Accounts

 

 

 

 

 

 

 

 

 

 

 

Scholarship Payments

 

 

 

 

 

 

 

 

 

 

 

Prizes/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Capital Gains

 

 

 

 

 

 

 

 

 

 

 

Alimony/Maintenance

 

 

 

 

 

 

 

 

 

 

 

Lump Sum Amount

 

 

 

 

 

 

 

 

 

 

 

Alaskan Native Income

 

 

 

 

 

 

 

 

American Indian Income

 

 

 

 

 

 

 

 

Other Income

 

 

 

 

 

 

 

 

 

 

 

 

 

27. DEDUCTIONS: Mark all that apply, give the amount and how often you receive that amount. If you pay for certain things that can be

 

 

 

 

 

 

 

 

 

deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

 

 

 

 

 

 

 

 

 

NOTE: You should not include a cost that you already considered in your answer to net self-employment (Question 26b).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Deduction

 

 

 

 

 

 

 

X

 

Amount $

 

 

 

How Often

 

Deduction

 

 

 

 

 

 

 

 

X

 

Amount $

 

How Often

 

 

 

 

Alimony/Maintenance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student Loan Interest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Deduction:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Deduction:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. YEARLY INCOME: Complete only if your income changes each month. If you don’t expect changes to your monthly income, skip to

 

 

 

 

 

 

 

 

 

 

question 30.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your total income this year:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your total income next year (if you think it will be different):

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29. UNPAID MEDICAL BILLS Do you need help paying for medical bills from this month?

 

 

 

Yes

 

 

No

 

Do you need help paying for medical bills in the last3 months?

Yes

 

 

No Are these bills from aMedical Emergency?

Yes

Was your household size the same during the last 3 months as itis now?

 

 

Yes

No

 

 

 

 

Was your household income the same during the last 3 months as itis now?

Yes

 

 

 

 

No

 

 

 

 

If no, What was the household size and income during those 3 months?

NOTE: Arkansas Works recipients may be eligible for retroactive coverage 30 days prior to the date of application.

30. DISABILITY STATUS Do you have a disability?

Yes

No

Or are you blind?

Yes No

Do you live in a medical facility or nursing home?

Yes

No

 

 

What type of facility is this?

Nursing Home

Human Development Center

Arkansas State Hospital

Arkansas Health Center

Intermediate Care Facility for the Intellectually Disabled

 

Do you have a physical, mental or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc.)?

Yes

No

No

DCO-152 (09/18)

Page 4 of 8

Step 2: Person 2

Complete Step 2 for your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 2 for more information about who to include. If you don’t file a tax return, remember to still add family members who live with you.

1. First Name, Middle Name, Last Name & Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Relationship to you?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Date of Birth (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Sex

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Social Security Number (SSN) _ _ _ - _ _ - _ _ _ _ We need this if you want health coverage and have an SSN.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Does PERSON 2 live at the same address as you?

Yes

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If no, list address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Does PERSON 2 live in Arkansas?

Yes

No

 

8. If currently out-of-state, does PERSON 2 intend to return to Arkansas?

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Is PERSON 2 the main caregiver living with and taking

care of at least one child under the age of 19?

 

 

 

Yes

No

 

10. Does PERSON 2 currently have health coverage and want to continue with the same coverage?

 

Yes

No

 

 

 

 

 

If no, would PERSON 2 like to applyfor coverage?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITIZENSHIP STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Is PERSON 2 a U.S. citizen or U.S. national?

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

12. Is PERSON 2 a citizen of the Marshall Islands, Federated States of Micronesia or Palau?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. If PERSON 2 is not a U.S. citizen or U.S national, do they have eligible immigration status?

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes Enter your document type and ID number below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

Immigration document type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alien #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Document ID number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration date of document

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Has PERSON 2 lived in the U.S. since 1996?

Yes

 

 

 

No Date of entry into U.S.

 

 

 

 

 

 

 

 

 

 

_

 

 

 

 

d. Is PERSON 2 or their spouse or parent a veteran or an active duty member of the U.S. military?

 

 

 

Yes

No

 

14. If Hispanic/Latino, what is PERSON 2’s ethnicity and race? (OPTIONAL – Check all that apply.)

 

 

 

 

 

 

 

 

 

 

 

 

 

Mexican

 

 

Mexican-American

 

 

 

Chicano/a

 

 

 

 

Puerto Rican

 

 

 

Cuban

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Race (OPTIONAL – Mark (X) all that apply.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race

X

Race

 

X

Race

 

 

 

 

 

 

X

 

 

Race

 

X

Race

 

 

 

 

 

 

X

Race

 

X

 

 

White

 

Filipino

 

 

Black/African American

 

 

 

 

Alaskan Native

 

 

 

 

 

Hawaiian/Pacific Islander

 

 

 

Samoan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Korean

 

Japanese

 

American Indian

 

 

 

 

 

 

 

Asian Indian

 

 

 

 

 

Guamanian or Chamorro

 

 

 

Chinese

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREGNANCY STATUS

 

 

Yes

No

If Yes, what is the expected due date?

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

16. Is PERSON 2 pregnant?

 

 

 

 

 

 

 

 

How many babies is PERSON 2 expecting during this pregnancy?

 

 

 

 

 

 

If no, has PERSON 2 delivered a child in the

 

last 90 days? Y

es No If yes, what was the date of delivery?

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, how many babies did PERSON 2 deliver?

 

 

 

 

 

 

 

 

 

 

 

Is Person 2 a newborn? Yes

 

 

 

 

No

 

 

 

 

 

If yes, What is the biological mother’s name and date of birth?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABSENT PARENT INFORMATION

17. Please provide ABSENT PARENT information: First Name: ____________________________ Last Name: _____________________________

Social Security Number (SSN): _ _ _-_ _-_ _ _ _ Date of birth (mm/dd/yy) _ _/_ _/ _ _ Address: ________________________________________

Phone (____) __________ Relationship to child: ________________ Why is the parent absent from the home? ___________________________

You may claim to have good cause for refusing to provide absent parent information if you believe that it would not be in the best interest of you or your child (ren) and you must provide evidence to support this good cause claim. Would you like to claim good cause for this absent parent?

Yes

No

If yes, please provide your good cause reason:

 

 

 

 

FOSTER CARE STATUS

 

 

 

 

 

 

18. Was PERSON 2 in foster care in Arkansas at age 18 or older?

Yes

No

 

 

If yes, was PERSON 2 enrolled in Medicaid when they left the Foster Care program?

Yes

No

Is PERSON 2 currently enrolled in Medicaid?

Yes

No

 

 

 

 

TAX FILING STATUS

19. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for health coverage even if you don’t file a federal

income tax return.)

 

 

NO If no, skip to question c.

YES If yes, please answer questions a through

 

 

a.

Will PERSON 2 file jointly with a spouse?

Yes

No

 

 

 

 

 

 

If yes, name ofspouse:

 

 

 

 

 

 

 

 

b.

Will PERSON 2 claim any dependents on his or her tax return?

 

Yes

No

 

If yes, list name(s) of dependents:

 

 

 

 

 

 

 

 

c.

Will PERSON 2 be claimed as a dependent on someone’s tax return?

Yes

No

 

If yes, please list the name of the tax filer:

 

 

 

 

_

 

How is PERSON 2 related to the tax filer?

 

 

 

 

 

 

 

 

 

DCO-152 (09/18)

Page 5 of 8

Step 2: Person 2 (Continued)

CURRENT JOB & INCOME INFORMATION

Employed

Not Employed

Self Employed

If PERSON 2 currently employed tell us about

Skip to Question 28.

Skip to Question 29.

their income. Start with question 20.

 

 

CURRENT JOB 1:

20. Employer Name and Address

22. Wages/tips (before taxes)

$

 

 

 

 

 

Hourly

Weekly

Every 2 Weeks

Twice a Month

Monthly

Yearly

21. Employer Phone Number

23. Average hours worked each week:

 

 

 

Start date of employment

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT JOB 2: (Attach another sheet of paper to list more jobs.)

 

 

 

 

 

 

 

 

 

 

 

24. Employer Name and Address

 

 

 

 

 

 

 

 

 

 

25. Employer Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26. Wages/tips (before taxes)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hourly

Weekly

Every 2 Weeks

Twice a Month

Monthly

Yearly

 

 

 

 

 

27. Average hours worked each week:

 

 

Start date of employment

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. In the past year, did PERSON 2:

Change

 

 

 

Start working fewer

 

 

Stop working?

 

 

None of these?

 

 

 

 

 

 

 

jobs?

 

 

 

hours?

 

 

 

 

 

 

 

 

 

 

 

If PERSON 2 stopped working what was the date that the job ended?

 

 

 

 

 

 

 

 

 

 

 

29. If self-employed, answer the following questions:

 

 

 

 

 

 

 

 

 

 

 

a. Name of Business:______________________________________________________

 

 

 

 

 

b. How much net income (profits once business expenses are paid) will PERSON 2 receive from this self-employment this month? $___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30.OTHER INCOME THIS MONTH: Check all that apply and give the amount and how often you receive that amount. NOTE: You don’t need to tell us about child support, veteran’s payments or Supplemental Security Income (SSI).

INCOME

Amount

How Often

INCOME

Amount

How Often

INCOME

Amount

How Often

None

 

 

Taxable Interest

 

 

Tax Exempt Interest

 

 

Dividends

 

 

Foreign Income

 

 

Unemployment

 

 

Pensions/Retirement

 

 

Social Security

 

 

Net Farming/Fishing

 

 

Retirement Accounts

 

 

Scholarship Payments

 

 

Prizes/Awards

 

 

Capital Gains

 

 

Alimony/Maintenance

 

 

Lump Sum Amount

 

 

Alaskan Native Income

 

 

American Indian

 

 

Other Income

 

 

31. DEDUCTIONS: Mark all that apply, give the amount and how often you receive that amount. If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You should not include a cost that you already considered in your answer to net self-employment (Question 29b).

Deduction

X

Amount $

How Often

Deduction

X

Amount $

How Often

Alimony/Maintenance

 

 

 

Student Loan Interest

 

 

 

Other Deduction:_________________

 

 

 

Other Deduction: _________________

 

 

 

32.YEARLY INCOME: Complete only if PERSON 2’s income changes each month. If you don’t expect changes to PERSON 2’s monthly income, skip to question 33.

Your total income this year:

 

 

 

 

 

Your total income next year (if you think it will be different):

$

 

 

__

 

 

 

$

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33. UNPAID MEDICAL BILLS Does PERSON 2 need help paying for medical bills from this month?

 

Yes

 

 

 

No

 

Does PERSON 2 need help paying for medical bills in the last 3 months?

Yes No

 

 

 

 

 

 

 

 

 

Are these bills from a Medical Emergency?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was PERSON 2’s household size the same during the last 3 months as it is now?

Yes

No

 

 

 

 

 

 

 

Was PERSON 2’s household income the same during the last 3 months as it is now?

Yes

 

No

 

 

 

 

If no, what was the household size and income during those 3 months? ______________________

 

 

 

 

 

 

NOTE: Arkansas Works recipients may be eligible for retroactive coverage 30 days prior to the date of application.

34. DISABILITY STATUS Does PERSON 2 have a disability?

 

Yes

 

No

Or is PERSON 2 blind?

Yes

No

 

Does PERSON 2 live in a medical facility or nursing home?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

What type of facility is this?

Nursing Home

Human Development Center

 

Arkansas State Hospital

 

Arkansas Health Center

Intermediate Care Facility for the Intellectually Disabled

 

 

 

 

 

 

 

 

Does PERSON 2 have a physical, mental or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc.)? Yes

No

DCO-152 (09/18)

Page 6 of 8

Step 3: American Indian or Alaskan Native(AI/AN) Family Members

Are you or is anyone in your family an American Indian or an Alaskan Native?

No If no, skip to Step 4.

Yes If yes, please obtain and complete an Appendix B to the DCO-151/152 and submit it with this application.

Is anyone in the home eligible to receive Indian Program Services?

Yes

No

Step 4: Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

1. Is anyone enrolled in health coverage now from the following?

Yes

No

 

 

 

If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.

 

 

 

Name of Health Insurance

 

 

Other Insurance

 

 

 

 

 

 

 

 

 

 

Policy Number

 

 

Name of Health Insurance

 

 

Is this cobra coverage?

Yes

No

Policy Number

 

 

Is this a retiree plan?

Yes

No

Is this a limited benefit plan (like a schoolaccident policy)?

Yes

No

Other Health Coverage

 

 

 

 

 

 

 

Medicaid

 

 

 

ARKids First/CHIP

 

 

 

 

 

 

 

 

 

 

 

Medicare

 

 

 

Peace Corp

 

 

 

 

 

 

 

 

 

 

VA Health Care Programs

 

 

 

 

 

 

 

 

 

 

 

 

TRICARE (Don’t check if you have Direct Care or Line of Duty)

 

 

 

 

2.Is anyone listed on this application offered health coverage from a job? Check Yes, even if the coverage is from someone else’s job such as a parent or spouse.

 

Yes

If yes, you will need to complete and include Appendix A.

 

Is this a state employee benefit plan?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

If no, continue to the next question below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Has anyone listed on the application lost health insurance coverage in the last 90 days?

Yes

No

 

 

 

 

If yes, When did the coverage end?

 

Why did the coverage end?

 

 

 

 

 

 

Was the insurance a group or employersponsored plan?

 

Yes

No

 

 

 

 

 

 

Did the insurance cover both hospital andphysician charges?

 

Yes

No

 

 

 

 

 

INCARCERATION STATUS

Is anyone that is listed on this application currently incarcerated with the Department of Corrections, Department of Community Correction,

county jail, city jail or a JuvenileDetention Facility?

Yes

No

If Yes, who?

 

 

 

 

_

 

What is the incarcerated person’s expectedrelease date?

 

 

 

_ (mm/dd/yyyy)

Step 5: Read & Sign This Application

I am signing this application under penalty of perjury which means I have provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false or untrue information.

I know that I must tell the Department of Human Services (DHS) if anything changes (and is different than) what I wrote on this application. I can visit access.arkansas.gov or call 1-855-372-1084 to report any changes. I understand that a change in my information could affect the eligibility for members of my household.

I know that under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity or disability. I can file a complaint of discrimination by visiting hhs.gov/ocr/office/file or by calling 1-501-682-6003.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We will check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow DHS to use income data, including information from tax returns. DHS will send me a notice, let me make any changes and I can opt out at any time.

Yes, review my eligibility automatically for the next:

 

 

 

 

5 years (The maximum number of years allowed) Or for a shorter number of years:

4 years

3 years

2 years

1 year

Don’t use information from tax returns to review my eligibility.

 

 

 

 

DCO-152 (09/18)

Page 7 of 8

Step 5: Read & Sign This Application (Continued)

If anyone on this application is eligible for Medicaid, ARKids First or the Arkansas Works Program

I am giving to the Department of Human Services our rights to pursue and receive money from other health insurance, legal settlements or other third parties. I am also giving to the Medicaid agency rights to pursue and receive medical support from a spouse or parent.

I understand that 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.

I understand that if I am eligible for the Arkansas Works Program my information will be shared with the Arkansas Division of Workforce Services.

I understand that participation with the Arkansas Division of Workforce Services will not affect my eligibility for Medicaid or the Arkansas Works Program.

Does any child on this application have a parent living outside the home? YesNo

If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell DHS and I may not have to cooperate.

My right to appeal

If I think that DHS has made a mistake, I can appeal its decision. To appeal means to tell someone at DHS that I think the action is wrong and ask for a fair review of the action. I know that I can find out how to appeal by contacting Medicaid at 1-501-682-8622. I know I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Sign this application. The person who filled out Step 1 should sign this application. If you are an Authorized Representative you may sign here, as long as you have provided a signed copy of the DCO-153, Consent for an Authorized Representative.

Signature

Date

Step 6: Mail Completed Application

Send your complete, signed application to the address below. If you do not have all the information we ask for, sign and submit your application anyway.

Mail your signed application to:

 

DHS Pine Bluff Scanning Center

Or email the application to: 351Jefferson@arkansas.gov

P.O. Box 8848

Or fax the application to:1-870-534-3421.

Pine Bluff, AR 71611-8848

Or submit the application to your local DHS Office.

What happens next? We will process your application for Medicaid, ARKids First or the Arkansas Works Program and send you a notice to tell you if your application for coverage has been approved or denied and provide instructions on the next steps needed to complete your health coverage application. If you are not eligible for any of these programs, we will screen your application for potential eligibility for tax credits to help pay for health insurance premiums and then transfer your information to the Health Insurance Marketplace. We will provide instructions on how to complete the application process on the notice we send to you.

NEED HELP WITH YOUR APPLICATION? Call us at 1-855-372-1084. Para obtener una copia de este formulario en Español, llame 1-855-372-1084. If you need help in a language other than English, call 1-855-372-1084 and tell the customer service representative the language you need. We will get you help at no cost to you.

This completes the application process for Medicaid, ARKids First and the Arkansas Works Program. Federal law requires that each state provide the opportunity to register to vote with every application for public assistance. The remaining pages of this packet are the Arkansas Voter Registration Application.

Please answer the following question regarding voter registration:

Would you like to register to vote or change your voter registration

Yes

address?

 

No

If you marked Yes, please complete and sign the Voter Registration Application that is attached and submit it with your application.

DCO-152 (09/18)

Page 8 of 8

PLEASE PRINT AND USE BLACK INK TO COMPLETE

Rev. 6-13-17

ARKANSAS VOTER REGISTRATION APPLICATION

 

Check all that apply:

 

 

 

Office Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is a new registration.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is a name change.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is an address change.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is a party change.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assigned ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mr.

 

 

Last Name

 

 

 

 

 

 

Jr.

 

 

 

Sr.

First

Name

 

 

 

 

 

 

 

 

Middle Name

 

1

 

 

 

MissMrs.

 

 

 

 

 

 

 

 

 

 

 

 

 

II.

III. IV.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

Address

Where You Live (See Section “C” Below)

 

 

Apt. or Lot#

City/Town

 

County

 

 

 

 

 

State

ZIP Code

 

 

 

 

(Rural addresses must draw map.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

Address Where You Receive Mail If Different From Above

 

Apt. or Lot#

City/Town

 

County

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

Date of Birth

 

 

/

 

 

 

/

 

5

Home & Work Phone Numbers (Optional)

 

 

 

 

6

Party Affiliation (Optional)

 

 

 

 

 

 

Day

Year

(H)

 

 

 

 

 

 

 

 

 

(W)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address (Optional)

 

 

 

 

 

 

 

 

 

8

 

Have you ever voted in a federal election inthis State?

 

Yes

No

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of elector - Please sign full name or put mark.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID Number - Check the applicable box and provide the appropriate number.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

 

 

 

Arkansas Driver’s license number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you do not have a driver’s license provide the last 4 digits of social

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

security number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have neither a driver’s license nor social security number.

 

 

 

 

 

 

The information I have provided is true to the best of my knowledge. I do not claim the right

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(A)

 

Are you a citizen of the United States of America and an Arkansas resident?

 

 

 

to vote in another county or state. If I have provided false information, I may be subject to

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a fine of up to $10,000 and/or imprisonment of up to 10 years under state and federal laws.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(B)

Will

 

you

be

eighteen (18) years of age or older on or before election day?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

/

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(C)

 

you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

 

 

Are

presentlyadjudgedmentally incompetentbyacourtof competent

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

jurisdiction?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If applicant is unable to sign his/her name, provide name, address and phone

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

 

you

 

 

 

 

 

 

 

 

 

 

 

 

number of the person providing assistance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(D)Have

 

ever been convicted of a felony without your sentence having been

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

discharged or pardoned?

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you checked No in response to either questions A or B, do not complete this form.

 

City:

 

State:

 

Phone#:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you checked Yes in response to either questions C or D, do not complete this form.

Please complete the sections below if:

MAIL REGISTRANTS: PLEASE SEE SECTION D.

You were previously registered in another county or state, or

You wish to change the name or address on your current registration.

Agency Code (For Official Use Only)

PA 04

Date of Birth

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mr.

Previous Last Name

 

 

 

 

 

Jr.

Sr.

First Name

 

 

 

 

Middle Name

A

MissMrs.

 

 

 

 

 

 

 

 

 

 

II.

III. IV.

 

 

 

 

 

 

 

 

 

 

 

 

Ms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Previous House Number and Street Name

Apt. or Lot#

City/Town

 

 

County

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you live in a rural area but do not have a house or street number,

 

 

 

IDENTIFICATION REQUIREMENTS

 

 

 

 

 

 

 

 

 

 

or if you have no address, please show on the map where you live.

 

 

IMPORTANT: Applicants

will be

required to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

verify their registration when voting in person or by

 

• Write in the names of the crossroads (or streets) nearest where youlive.

 

 

 

 

 

absentee ballot by providing a required document

C

• Draw an “X” to show where you live.

 

 

 

 

 

 

 

 

 

 

 

 

or

identification card as

provided

in Arkansas

• Use a dot to show any schools, churches, stores or other landmarks near

 

 

 

 

Constitution, Amendment 51, Section 13. If your

 

where you live and write the name of the landmark.

 

 

 

 

 

 

 

 

 

 

 

 

 

voter registration application form is submitted by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

mail and you are registering for the first time, and

Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NORTH

 

you do not have a valid Arkansas driver’s license

 

 

 

 

 

Grocery

 

 

 

 

 

 

 

 

 

number or social security number, in order to avoid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the

additional identification requirements upon

 

 

 

 

<![endif]>#2

Store

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

voting for the first time you must submit with the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Woodchuck Road

 

 

 

 

 

 

 

 

 

 

<![endif]>Route

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mailed registration form: (a) a current and valid

Public School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

photo identification; or (b) a copy of a current utility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bill, bank statement, government check, paycheck,

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

or other government document that shows your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

name and address.

 

 

 

 

 

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 votecounts.

If you are qualified and the information on your form is complete, you will be notified of your voting precinct by your local County Clerk.

To Mail

Fold form on middle perforation, remove plastic strip, seal at bottom, stamp and mail.

Questions?

Call your local County Clerk

or

Arkansas Secretary of State

Mark Martin

Elections Division – Voter Services 1-800-482-1127

Contact your County Clerk if you have not received confirmation

of this application within two weeks.

How to Edit Arkids Application Online for Free

This PDF editor makes it simple to prepare documents. You should not perform much to manage arkids first application form documents. Just simply keep up with all of these steps.

Step 1: Step one is to select the orange "Get Form Now" button.

Step 2: The file editing page is presently open. It's possible to add text or manage present content.

Make sure you type in the next details to complete the ar, kids first application pdf PDF:

part 1 to filling in forms arkids online

Jot down the information in .

forms arkids online  fields to insert

Remember to provide the fundamental information from the part.

Entering details in forms arkids online part 3

The segment needs to be used to note the rights or obligations of each party.

part 4 to entering details in forms arkids online

Finalize by checking these areas and completing them as required: .

step 5 to entering details in forms arkids online

Step 3: When you click on the Done button, your completed document is conveniently exportable to any kind of of your gadgets. Or alternatively, you will be able to send it via email.

Step 4: In avoiding potential forthcoming difficulties, you should hold as much as two or more duplicates of each and every form.

Watch Arkids Application Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .