Dco 215 Form – Fill Out and Use This PDF

Arkansas Department of Human Services

Application for SNAP and TEA

(Food Assistance and Cash Assistance)

See if you qualify for SNAP and TEA online! Apply online at www.access.arkansas.gov!

The Supplemental Nutrition Assistance Program (SNAP) helps low-income people buy the food they need for good health. SNAP benefits supplement an individual’s or a family’s income to help buy nutritious food. Most households must spend some of their own money along with their SNAP benefits to buy the food they need.

You may be able to receive SNAP benefits if you are working for low wages; working part-time; unemployed; receiving public assistance payments; living with a disability; are older; or homeless. All participants must meet financial and non-financial criteria.

The Transitional Employment Assistance (TEA) Program helps economically needy families with children under the age of 18 become more responsible for their own support and less dependent on public assistance. TEA provides monthly cash assistance to eligible families to help meet the family's basic needs. TEA also provides supportive services such as child care assistance and employment related services while the parent or other adult relative works toward increasing his or her earning potential. State law limits the receipt of TEA benefits to 24 month lifetime limit.

You can have some income, including earnings, and still be eligible to receive TEA benefits, if your countable income is less than the income standard. You can have resources (cash, bank accounts, property not used as a home, etc.) if the total value of these resources does not exceed $3,000. TEA cash assistance is also available to help meet the needs of children who are being cared for by non-parent adult relatives. Assistance to such relatives may be provided for the children without regard to the time limit.

When should I apply?

It is important to turn in your application right away. If your household is eligible, your first month of SNAP benefits will be paid from the day that your application was received online or the date you submit a paper application in the DHS County Office. The TEA effective date of payment is the first day of the month your application is approved.

You have the right to submit a SNAP application with only the applicant's name, address, and the signature of a responsible household member or the household's authorized representative. However, providing a complete application may result in a quicker eligibility determination.

Do you need help completing your application?

	By Phone	In Person	En Español
			Llame a nuestro centro
	Customer Assistance	Contact your local DHS county office
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	1-800-482-8988	for more information
			1-800-482-8988

KEEP THE OUTER PORTION OF THIS APPLICATION FOR YOUR INFORMATION

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Interview requirements for both SNAP and TEA:

Households applying for SNAP and TEA are required to complete an interview for their eligibility determination. This interview can be in-person or over-the-phone. Households that apply online at www.access.arkansas.gov are automatically offered a telephone interview. Only one interview is necessary when applying for both SNAP and TEA. If you miss your appointment for an

interview, we will not schedule another appointment unless you ask us to do so.

Your household may choose someone who knows about your circumstances to complete the interview either in- person or over-the-phone. This person is called an “authorized representative”.

Helpful documents for SNAP and TEA:

A Social Security Number (SSN) or proof of application for an SSN for each household member applying for benefits.

Documentation of legal alien status for each non-citizen applying for benefits.

Proof of identity for the applicant.

Proof of residence.

Proof of all income.

Proof of the value of resources such as, but not limited to, bank accounts, certificates of deposit, stocks, bonds, and vehicles.

Proof of medical expenses for household members over the age of 60 or living with a disability, only if you want these expenses to be claimed.

Proof of current utility bills, only if you want to use your actual utility costs to calculate your SNAP benefit amount. NOTE: SNAP allows certain households to use a “utility standard.” Ask your worker if actual costs or the utility standard will be best for your household.

If you are applying for TEA benefits for a child, proof of that child's age and proof of that child's relationship to you.

How long does it take to process an application?

Most SNAP applications must be processed within 30 days. However, we must process your SNAP application within seven days (expedited service) if:

Your household has $100 or less in cash, bank accounts, or other liquid resources and less than $150 in countable income; OR

Your current shelter costs are more than your income and liquid resources; OR

You are a migrant or seasonal farm worker and your household has little or no income at the time you apply.

TEA applications should be processed within 30 days.

If you complete the screening questions in the SNAP Expedited Service section, we will determine if your household is entitled to expedited service in SNAP.

How will I know if my application has been approved or denied?

When we take action on your application for SNAP or TEA, we will send you a notice to tell you if your application has been approved or denied.

If I am eligible, how will I get my benefits?

If you participate in the SNAP and/or the TEA Program, you will receive an electronic benefits transfer (EBT) card that looks similar to a debit card. Your EBT card will be used to access your SNAP and/or TEA benefits. SNAP benefits may only be accessed at authorized retailers, such as grocery stores and approved farmers’ markets.

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What are my appeal rights?

If you are not satisfied with our actions or if we fail to act on your application for SNAP or TEA, you or your representative may ask for a hearing. There are three ways that you or your representative can request a hearing.

1.You may request a hearing by following the instructions listed on the back of the Notice of Action form you received regarding your application.

2.You may also ask for a hearing by calling the DHS County Office, writing a letter to the DHS County Office, or going to the DHS County Office.

3.You may also request a hearing by writing or calling the Appeals and Hearings Section:

Arkansas Department of Human Services	Telephone - (501) 682-8622
ATTN: Appeals and Hearings Section	TDD for Hearing Impaired – 501-682-6974
P.O. Box 1437, Slot N401	FAX - (501) 682-6605
Little Rock, AR 72203-1437

Who is ineligible to participate in SNAP and/or TEA?

•Any individual currently classified as a fugitive felon, parole violator, or probation violator.

•Any individual who was found guilty or who pled nolo contendere to a felony conviction involving

manufacture or distribution of a controlled substance.

Note: If a household has a mix of eligible and ineligible individuals, the eligible individuals may receive SNAP benefits as long as they meet all other program criteria.

Intentional Program Violations

Supplemental Nutrition Assistance Program

People who participate in the Supplemental Nutrition Assistance Program must follow these rules:

Do not give false information or withhold information in order to get or to continue to get SNAP benefits.

Do not alter any authorization document to get SNAP benefits you are not eligible to receive.

Do not use SNAP benefits to buy non-food items like alcoholic drinks, tobacco, or personal grooming items.

Do not trade or sell SNAP benefits or allow unauthorized use of electronic benefits transfer (EBT) cards.

Do not use someone else’s SNAP EBT card for your household’s benefit.

Do not buy or sell or attempt to buy or sell SNAP benefits or Electronic Benefits Transfer (EBT) cards for cash or for consideration other than eligible foods in public and online. Buying and selling or attempting to buy or sell your EBT card is called trafficking and may cause you to lose your benefits or be taken off the program permanently (forever).

An intentional program violation (IPV) occurs when you or any member of your household: 1) Makes a false or misleading statement or misrepresents, conceals or withholds facts; or 2) Commits any act that constitutes a violation of the Food and Nutrition Act, SNAP Regulations, or State Statute for the purpose of using, presenting, transferring, acquiring, receiving, possessing, or trafficking of SNAP authorization cards, or reusable documents used as part of an automated benefit delivery system. Anyone found to have committed an IPV will be disqualified from SNAP participation for: one year for the first violation, two years for the second violation, and permanently for the third violation. He or she may also be fined or imprisoned or both, and may be subject to federal prosecution and penalties.

Special disqualification periods apply when an individual is found guilty of any of the following violations:

Making a fraudulent statement or representation about identity or residence in order to get SNAP benefits in two locations during the same month – a ten-year disqualification.

Buying or selling controlled substances in exchange for SNAP benefits – a 24 month disqualification for the first violation and a permanent disqualification for the second violation.

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Buying or selling firearms, ammunition, or explosives in exchange for SNAP benefits – a permanent disqualification.

Trafficking SNAP benefits in excess of $500 – a permanent disqualification.

Intentional Program Violations

TEA Program

People who participate in TEA must follow these rules:

If you give any information that is false or misleading or if you withhold or conceal facts for the purpose of establishing or maintaining your family's eligibility for TEA, you may be found guilty of committing an intentional program violation (IPV) by an Administrative Hearing or through a court of law.

If you plead guilty or nolo contendere (no contest) or are found guilty of an IPV, your family will be ineligible for TEA for one year for the first offense, two years for the second offense and permanently for any subsequent offense. In addition, your family will remain ineligible to receive TEA benefits until the resulting overpayment is repaid to the State.

If you are found guilty of giving false information about your residence in order to receive TANF assistance in two or more states at the same time, your family will be ineligible for TEA assistance for a minimum of ten years beginning with the date of conviction. (The TEA Program is Arkansas' TANF Program.)

Did you know that if you are eligible for SNAP or TEA, you may be eligible for the following programs?

Housing assistance through HUD. Visit www.hud.gov for more information.

Assistance for utility costs through the Home Energy Assistance Program (HEAP). Visit www.acaaa.org to learn which agency serves your county.

Certain Medicaid categories. Visit www.access.arkansas.gov or visit your local DHS county office to apply for Medicaid.

Help with your telephone service through Lifeline and Link Up or visit www.lifelinesupport.org to apply. Ask your current telephone provider for more information.

Free or reduced tax preparation service through certain companies. Contact your tax preparer to see if they offer these services.

Free or reduced legal services. Contact local legal offices for a referral in your area.

Free school meals for children attending public schools. Children will be automatically enrolled through an administrative matching program.

Your Right to Privacy

The PRIVACY ACT of 1974 requires the Department of Human Services (DHS) to tell you: (1) whether disclosure is voluntary or mandatory; (2) how DHS will use your SSN; and, (3) the law or regulation that allows DHS to ask you for the SSN. We are authorized to collect from your household certain information including the social security number (SSN) of each eligible household member. For the Supplemental Nutrition Assistance Program this authority is granted under the Food and Nutrition Act of 2008 as amended, 7 U.S.C. 2001-2036. For both the Medicaid Program and the TEA Program, this authority is granted under Federal laws codified at 42 U.S.C. §§ 1320b-7(a)(1) and 1320b-7(b)(2). This information may be verified through computer matching programs. We will use this information to determine program eligibility, to monitor compliance with program rules, and for program management. This information may be disclosed to other Federal and State agencies and to law enforcement officials. If claim arises against your household, the information on this application, including all SSNs, may be provided to Federal or State officials or to private agencies for collection purposes.

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DHS County Office Mailing Addresses

County	Address	City	Zip	County	Address	City	Zip	County	Address	City	Zip
Arkansas	100 Court Square	DeWitt	72042	Grant	PO Box 158	Sheridan	72150	Ouachita	PO Box 718	Camden	71711
Arkansas	PO Box 1008	Stuttgart	72160	Greene	809 Goldsmith Road	Paragould	72450	Perry	213 Houston Ave.	Perryville	72126
Ashley	PO Box 190	Hamburg	71646	Hempstead	116 N. Laurel	Hope	71801	Phillips	PO Box 277	Helena	72342
Baxter	PO Box 408	Mt. Home	72654	Hot Spring	2505 Pine Bluff St.	Malvern	72104	Pike	PO Box 200	Murfreesboro	71958
Benton	900 SE 13th Court	Bentonville	72712	Howard	PO Box 1740	Nashville	71852	Poinsett	PO Box 526	Harrisburg	72432
Boone	PO Box 1096	Harrison	72601	Independence	100 Weaver Ave	Batesville	72501	Polk	P.O. Box 1808	Mena	71953
Bradley	PO Box 509	Warren	71671	Izard	PO Box 65	Melbourne	72556	Pope	701 N. Denver	Russellville	72801
Calhoun	PO Box 1068	Hampton	71744	Jackson	PO Box 610	Newport	72112	Prairie	PO Box 356	DeValls Bluff	72041
Carroll	PO Box 425	Berryville	72616	Jefferson	PO Box 5670	Pine Bluff	71611	Pulaski East	PO Box 8083	Little Rock	72203
Chicot	PO Box 71	Lake Village	71653	Johnson	PO Box 1636	Clarksville	72830	Pulaski Jax.	PO Box 626	Jacksonville	72078
Clark	PO Box 969	Arkadelphia	71923	Lafayette	2612 Spruce St.	Lewisville	71845	Pulaski No.	PO Box 5791	N. Little Rock	72119
Clay	PO Box 366	Piggott	72454	Lawrence	PO Box 69	Walnut Ridge	72476	Pulaski So.	PO Box 2620	Little Rock	72203
Cleburne	PO Box 1140	Heber Springs.	72543	Lee	PO Box 309	Marianna	72360	Pulaski Sw.	PO Box 8916	Little Rock	72219
Cleveland	PO Box 465	Rison	71665	Lincoln	101 W. Wiley St.	Star City	71667	Randolph	1408 Pace Rd.	Pocahontas	72455
Columbia	PO Box 1109	Magnolia	71754	Little River	90 Waddell St.	Ashdown	71822	Saline	1603 Edison Ave.	Benton	72018
Conway	PO Box 228	Morrillton	72110	Logan-1	#17 W. McKeen	Paris	72855	Scott	PO Box 840	Waldron	72958
Craighead	PO Box 16840	Jonesboro	72403	Logan-2	398 E. 2nd St.	Booneville	72927	Searcy	106 School St.	Marshall	72650
Crawford	704 Cloverleaf Circle	Van Buren	72956	Lonoke	PO Box 260	Lonoke	72086	Sebastian	616 Garrison	Ft. Smith	72901
Crittenden	401 S. College Blvd	W. Memphis	72301	Madison	PO Box 128	Huntsville	72740	Sevier	PO Box 670	DeQueen	71832
Cross	803 E. Hwy 64	Wynne	72396	Marion	PO Box 447	Yellville	72687	Sharp	1467 Hwy 62/412	Cherokee	75229
									Ste. B	Village
Dallas	1202 W. 3rd St.	Fordyce	71742	Miller	3809 Airport Plaza	Texarkana	71854	St Francis	PO Box 899	Forrest City	72336
Desha	PO Box 1009	McGehee	71654	Mississippi 1	1104 Byrum Rd.	Blytheville	72315	Stone	1821 E Main	Mountain View	72560
Drew	PO Box 1350	Monticello	71657	Mississippi 2	437 S Country Club	Osceola	72370	Union	123 W. 18th St.	El Dorado	71730
Faulkner	1000 E.	Conway	72032	Monroe-1	PO Box 354	Clarendon	72029	Van Buren	449 Ingram St.	Clinton	72031
	Siebenmorgan
Franklin	800 W Commercial	Ozark	72949	Monroe-2	301½ N New Orleans	Brinkley	72021	Washington	4044 Frontage	Fayetteville	72703
Fulton	PO Box 650	Salem	72576	Montgomery	PO Box 445	Mt. Ida	71957	White	608 Rodgers Drive	Searcy	72143
Garland	115 Stover Lane	Hot Springs	71913	Nevada	PO Box 292	Prescott	71857	Woodruff	PO Box 493	Augusta	72006
				Newton	PO Box 452	Jasper	72641	Yell	PO Box 277	Danville	72833

Fold in half and tape ends together.

Use the addresses above to mail your application to your local DHS County Office

Return Address

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Mail or bring to your local DHS county office

ARKANSAS VOTER REGISTRATION INFORMATION

Section 7 of the National Voter Registration Act (NVRA) of 1993 requires that each state provide the opportunity to register to vote with every application for public assistance and every recertification, renewal and change of address. This Voter Registration packet is an opportunity for you to register to vote or change your voter registration address. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration application form in private.

No information relating to a declination to register to vote in connection with an application may be used for any purpose other than voter registration.

If you believe that someone has interfered with your right to: 1) Register to vote;

2)Decline to register to vote; 3) Privacy in deciding whether to register or in applying to register to vote; or 4) Choose your own political party or other political preference,

You may file a complaint with:

Secretary of State Room 256 State Capitol Little Rock, Arkansas 72201 1-800-482-1127

Mailing Instructions for Voter Registration

You have two options to submit your Voter Registration form.

1.You can submit the registration form in person or mail the registration form along with your SNAP or Medicaid application to your local county DHS office. The address for your county office can be found on the last page of this packet. Some applications (DCO-151 & DCO-152) must be mailed to the Jefferson County DHS office. If you are using one of these forms, you can mail the Voter Registration form with your application to that office. Upon receipt at any county office, that office will mail the form to the Secretary of State’s office for you.

2.You may also mail the Voter Registration form directly to the Secretary of State’s Office. To mail the form directly to the Secretary of State’s office, separate the form from your application/renewal, fold the form along the middle perforation, seal the bottom with tape or staple, and mail to the address on the form. A stamp or stamped envelope is required for mailing.

DCO-0137 (R. 04/15)