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?
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By Phone |
In Person |
En Español |
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Llame a nuestro centro |
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Customer Assistance |
Contact your local DHS county office |
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de ayuda gratis al |
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1-800-482-8988 |
for more information |
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1-800-482-8988 |
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KEEP THE OUTER PORTION OF THIS APPLICATION FOR YOUR INFORMATION
Wrap-1 (Rev. 8/2015)
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.
Wrap-2 (Rev. 8/2015)
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 |
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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.
Wrap-3 (Rev. 8/2015)
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.
Wrap-4 (Rev. 8/2015)
Arkansas Department of Human Services
Application for SNAP and TEA
IF 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 Name |
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Date of Birth |
Work Phone |
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Mailing Address (P.O. Box, Street, Apt./Lot #) |
City |
State |
Zip |
Home or Cell Phone |
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Residence Address (Street, Apt./Lot #) |
City |
State |
Zip |
E-mail Address |
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What Services Are You Requesting? Please use blue or black ink.
Supplemental Nutrition Assistance Program (SNAP)
Are you currently receiving SNAP benefits? YES NO
If you believe your household needs SNAP benefits right away, complete the questions on page 2 of this form. If you do, 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 NO
1. |
Have you or anyone in your household received assistance in another state? |
YES NO |
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If yes, check all that apply. |
SNAP TEA |
2. |
Do you have or have you ever had an electronic benefits transfer (EBT) card in Arkansas? |
YES NO |
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If yes, do you currently have the card? |
YES NO |
3. |
Have you or any household member been found guilty of or pled guilty or nolo contendere (no |
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contest) to a felony conviction involving the manufacture or distribution of a controlled |
YES NO |
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substance? |
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4. |
Would you like to register to vote? |
YES NO |
5. |
Would you prefer an in-person interview or an interview by telephone? |
In-person |
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Telephone |
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If you selected a telephone interview, you must provide a working phone number. Be sure to |
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have phone service or minutes available. |
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Household Members: List all the people who live in your home, including yourself. If needed, attach a sheet of paper listing additional members.
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Does this |
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Full name |
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Relationship |
person buy and |
Is this person a |
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Security |
Birthdate |
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(First, middle, and last) |
to you |
prepare meals |
U.S. Citizen? |
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Number |
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separately? |
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YES NO |
YES NO |
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YES NO |
YES NO |
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YES NO |
YES NO |
Federal law requires that each state provide the opportunity to register to vote with every application for public assistance. Please answer the following question regarding voter registration:
•Would you like to register to vote or change your voter registration address? Yes No
If you marked Yes, please complete and sign the Voter Registration Application that is attached. If you marked No, submit your application to your local DHS 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 and information provided by the sources listed above, DHS may contact other sources for verification. I understand that this information may affect my household’s eligibility for benefits. 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 of Witness if applicant signs with an “X”:
DCO-215 (Rev. 4/2016)
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.
SNAP Expedited Service for All Households:
What is your household’s total monthly income before deductions?
Deductions are amounts taken out for taxes, insurance, etc. The monthly total must include
1.money that you and other household members receive from work and money received in the form of checks or cash. Also, you must include money that you and other members of your household have already received so far this month and money that you will be receiving 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 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. |
Is anyone in your household a migrant or a seasonal farm worker? |
YES NO |
2. |
Did your household’s income recently stop? |
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YES NO |
3. |
Do you or anyone else in your household expect income from a new source this month? |
YES NO |
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(A) If yes, how much will the income be? |
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$ |
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(B) When do you expect to receive the income? |
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DATE: |
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County Use Only |
Expedited: |
YES NO |
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Screener: |
Screen Date: |
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LD Date: |
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Notes: |
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Ethnicity Declaration: DHS is required to ask for racial and ethnic data on households applying for or participating in SNAP. You are not required to complete this section in order to receive assistance. If you are approved, your benefit level will not be affected by your decision to complete or not complete this section. DHS encourages you to answer the questions below.
1. Are you Hispanic or Latino? (Select only one) YES NO
2. What is your race? (Select one or more)
American Indian or Alaskan Native
Asian
Black or African American
Pacific Islander or Native Hawaiian
White
Other
Income: 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 |
Retirement/Pension/Annuity |
Self-employment Income |
Americorp VISTA/Americorp |
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Program Income |
Child Support/Alimony |
Military Allotment |
Cash Contributions |
Railroad or Veteran’s benefits |
Income from rental property |
Other ______________ |
Resources
Checking/Savings Account |
Campers/RV (Motor Home) |
Stocks/Bonds/Mutual Funds |
Trust Fund |
Motorcycle or ATV |
Mobile Home |
Certificate of Deposit (CD) |
Golf cart/ Go-cart/ Moped |
Burial Plots/Prepaid Plan |
Christmas Club Account |
Car/Truck/Van |
Real Estate (not your home) |
IRA/ KEOGH/ 401K |
Boats/ Motors/Trailers |
Other _______________ |
Have you or anyone in your home sold or given away any resource in the past 3 months? YES NO
DCO-215 (Rev. 4/2016)
Expenses: Please check each type of expense that you or anyone else in your home pays.
Rent |
Insurance on home |
Baby sitter or day care |
Mortgage Payment |
Utilities |
Medical costs |
Taxes on home |
Telephone |
Child support |
Failure to report and verify any of the above listed expenses will be seen as a statement by your household that you do not want to receive a deduction for unreported expenses.
Students: Is anyone in your home currently enrolled in a college, vocational school, technical school or any
other training program beyond high school? YES NO |
If yes, complete the section below. |
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1. |
Name of student |
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2. |
School or training program |
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3. |
Enrollment status |
Full-time Part-time |
4. |
Is the student a Work-Study Program participant? |
YES NO |
Authorized Representative: If you want to choose someone to represent you, please complete the following information. If you name an authorized representative, this person will be able to take your place at the interview and talk to the DHS county worker on your behalf.
Name
Mailing Address (P.O. Box, Street, Apt./Lot #)
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in 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, 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.
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 letter all of 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:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, 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 or refuses to provide any of this information will not be eligible to receive SNAP and/or TEA benefits. Other household members who do provide 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 unless exempt from the RTW or Work Registration. The RTW rule only applies to Able Bodied Adults without Dependents or ABAWDs who are 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 3 months out of a 3-year period. However, if work requirements are met, benefits may continue. Your caseworker can provide more information.
You can continue to receive SNAP benefits as long as you are eligible under Program rules. This is true even if someone in your home receives TEA/Works Pays cash assistance. If someone in your home does receive TEA/Works Pays cash assistance, participation in SNAP 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 your most recent paycheck stubs, award letters, and bank statements to your interview may speed up the application process. During the interview, the DHS worker will tell you if you must provide any additional information.
DCO-215 (Rev. 4/2016)
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 |
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Ste. B |
Village |
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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 |
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Siebenmorgan |
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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 |
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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
Place
Stamp
Here
Mail or bring to your local DHS county office
PLEASE PRINT AND USE BLACK INK TO COMPLETEREV. 7/12
ARKANSAS VOTER REGISTRATION APPLICATION
Check all that apply: |
Office Use Only |
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This is a new registration. |
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This is a name change. |
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This is an address change. |
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Assigned ID |
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This is a party change. |
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Mr. |
Last Name |
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Jr. |
Sr. |
First Name |
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Middle Name |
1 |
Mrs. |
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II. III. |
IV. |
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Miss |
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Ms. |
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Address Where You Live (See Section “C” Below) |
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Apt. or Lot # City/Town |
County |
State Zip Code |
2(Rural addresses must draw map.)
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Address Where You Receive Mail If Different From Above |
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Apt. or Lot # City/Town |
County |
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State |
Zip Code |
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4 |
Date of Birth |
_________/ |
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/_____________ |
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5 |
Home & Work Phone Numbers (Optional) |
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6 |
Party Affiliation (Optional) |
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Year |
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(H) |
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(W) |
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7 |
E-mailAddress(Optional) |
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8 |
Have you ever voted in a federal election in this State? |
Yes |
No |
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Signature of elector - Please sign full name or put mark. |
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ID Number - Check the applicable box and provide the appropriate number. |
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9 |
Arkansas Driverʼs license number _________________________________ |
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If you do not have a driverʼs license provide the last 4 digits of social |
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security number _______________________________ |
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I have neither a driverʼs license nor social security number. |
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_______________________________________________________________________ |
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(A) Are you a citizen of the United States of America and an Arkansas resident? |
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The information I have provided is true to the best of myknowledge. I do not claim the right |
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Yes |
No |
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to vote in another county or state. If I have provided false information, I may be subject to |
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10 (B) Will you be eighteen (18) years of age or older on or before election day? |
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afineofupto$10,000and/orimprisonmentofupto10yearsunderstateandfederallaws. |
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Yes |
No |
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(C) Are you presently adjudged mentally incompetent by a court of competent jurisdiction? |
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Date: _______________/______________/____________________ |
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Yes |
No |
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(D)Have you ever been convicted of a felony without your sentence having been |
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If applicant is unable to sign his/her name, provide name, address and |
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discharged or pardoned? |
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phone number of the person providing assistance: |
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Name: ______________________ |
Address: _________________________ |
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Yes |
No |
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If you checked No in response to either questions A or B, do not complete this form. If |
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City:_____________________ State: _______ Phone#:_________________ |
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Please complete the sections below if: |
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MAIL REGISTRANTS: PLEASE SEE SECTION D. |
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•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 _________/ |
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Month |
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Day |
Year |
Previous House Number and Street Name
If you live in a rural area but do not have a house or street number, or if you have no address, please show on the map where you live.
•Write in the names of the crossroads (or streets) nearest where you live.
•Draw an “X” to show where you live.
C• Use a dot to show any schools, churches, stores or other landmarks near where you live and write the name of the landmark.
IDENTIFICATION REQUIREMENTS
IMPORTANT: If your voter registration application form is submitted by mail and you are registering for the first time, and you do not have a valid
Arkansas driver's license number or social security number, in order to avoid the additional identification requirements upon voting for the first time you must submit with the mailed registration form: (a) a current and valid photo identification; or
(b)a copy of a current utility bill, bank statement, government check, paycheck, or other government document that shows your name and address.
Required
Postage
Class First
8111-72203 Arkansas Rock, Little
8111 Box .O.P
Registration Voter ATTN:
State of Secretary Arkansas
__________________
__________________
__________________
_____________From:
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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 donʼt delay.
Make sure your vote counts.
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, tape the form closed, 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.
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)
DHS County Office Mailing Addresses
County |
Address |
City |
Zip |
Arkansas |
100 Court Square |
DeWitt |
72042 |
Arkansas |
PO Box 1008 |
Stuttgart |
72160 |
Ashley |
PO Box 190 |
Hamburg |
71646 |
Baxter |
PO Box 408 |
Mt. Home |
72654 |
Benton |
900 SE 13th Court |
Bentonville |
72712 |
Boone |
PO Box 1096 |
Harrison |
72602 |
Bradley |
PO Box 509 |
Warren |
71671 |
Calhoun |
PO Box 1068 |
Hampton |
71744 |
Carroll |
PO Box 425 |
Berryville |
72616 |
Chicot |
PO Box 71 |
Lake Village |
71653 |
Clark |
PO Box 969 |
Arkadelphia |
71923 |
Clay |
PO Box 366 |
Piggott |
72454 |
Cleburne |
PO Box 1140 |
Heber Springs. |
72543 |
Cleveland |
PO Box 465 |
Rison |
71665 |
Columbia |
PO Box 1109 |
Magnolia |
71754 |
Conway |
PO Box 228 |
Morrilton |
72110 |
Craighead |
PO Box 16840 |
Jonesboro |
72403 |
Crawford |
704 Cloverleaf Circle |
Van Buren |
72956 |
Crittenden |
401 S. College Blvd |
W. Memphis |
72301 |
Cross |
803 Hwy 64E |
Wynne |
72396 |
Dallas |
1202 W. 3rd St. |
Fordyce |
71742 |
Desha |
PO Box 1009 |
McGehee |
71654 |
Drew |
PO Box 1350 |
Monticello |
71657 |
Faulkner |
1000 East |
Conway |
72032 |
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Siebenmorgan Road |
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Franklin |
800 W Commercial |
Ozark |
72949 |
Fulton |
PO Box 650 |
Salem |
72576 |
Garland |
115 Stover Lane |
Hot Springs |
71913 |
County |
Address |
City |
Zip |
Grant |
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PO Box 158 |
Sheridan |
72150 |
Greene |
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809 Goldsmith Rd |
Paragould |
72450 |
Hempstead |
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116 N. Laurel |
Hope |
71802 |
Hot Spring |
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2505 Pine Bluff St |
Malvern |
72104 |
Howard |
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PO Box 1740 |
Nashville |
71852 |
Independence |
100 Weaver Ave |
Batesville |
72501 |
Izard |
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PO Box 65 |
Melbourne |
72556 |
Jackson |
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PO Box 610 |
Newport |
72112 |
Jefferson |
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PO Box 5670 |
Pine Bluff |
71611 |
Johnson |
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PO Box 1636 |
Clarksville |
72830 |
Lafayette |
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2612 Spruce St. |
Lewisville |
71845 |
Lawrence |
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PO Box 69 |
Walnut Ridge |
72476 |
Lee |
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PO Box 309 |
Marianna |
72360 |
Lincoln |
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101 W. Wiley St. |
Star City |
71667 |
Little River |
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90 Waddell St. |
Ashdown |
71822 |
Logan-1 |
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#17 W. McKeen |
Paris |
72855 |
Logan-2 |
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398 East 2nd St. |
Booneville |
72927 |
Lonoke |
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PO Box 260 |
Lonoke |
72086 |
Madison |
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PO Box 128 |
Huntsville |
72740 |
Marion |
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PO Box 447 |
Yellville |
72687 |
Miller |
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3809 Airport Plaza |
Texarkana |
71854 |
Mississippi |
1 |
1104 Byrum Rd. |
Blytheville |
72315 |
Mississippi |
2 |
437 S Country Club |
Osceola |
72370 |
Monroe-1 |
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PO Box 354 |
Clarendon |
72029 |
Monroe-2 |
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301½ N New Orleans |
Brinkley |
72021 |
Montgomery |
PO Box 445 |
Mount Ida |
71957 |
Nevada |
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PO Box 292 |
Prescott |
71857 |
Newton |
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PO Box 452 |
Jasper |
72641 |
County |
Address |
City |
Zip |
Ouachita |
PO Box 718 |
Camden |
71711 |
Perry |
213 Houston Ave |
Perryville |
72126 |
Phillips |
PO Box 277 |
Helena |
72342 |
Pike |
PO Box 200 |
Murfreesboro |
71958 |
Poinsett |
PO Box 526 |
Harrisburg |
72432 |
Polk |
PO Box 1808 |
Mena |
71953 |
Pope |
701 N Denver |
Russellville |
72801 |
Prairie |
PO Box 356 |
DeValls Bluff |
72041 |
Pulaski East |
PO Box 8083 |
Little Rock |
72203 |
Pulaski Jax. |
PO Box 626 |
Jacksonville |
72078 |
Pulaski No. |
PO Box 5791 |
N. Little Rock |
72119 |
Pulaski So. |
PO Box 2620 |
Little Rock |
72203 |
Pulaski Sw. |
PO Box 8916 |
Little Rock |
72219 |
Randolph |
1408 Pace Rd |
Pocahontas |
72455 |
Saline |
PO Box 608 |
Benton |
72018 |
Scott |
PO Box 840 |
Waldron |
72958 |
Searcy |
106 School St |
Marshall |
72650 |
Sebastian |
616 Garrison Ave |
Ft. Smith |
72901 |
Sevier |
PO Box 670 |
DeQueen |
71832 |
Sharp |
1467 Hwy 62/412 |
Cherokee Village |
72529 |
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Ste. B |
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St Francis |
PO Box 899 |
Forrest City |
72336 |
Stone |
1821 E Main |
Mountain View |
72560 |
Union |
123 W 18th St. |
El Dorado |
71730 |
Van Buren |
449 Ingram Street |
Clinton |
72031 |
Washington |
4044 Frontage |
Fayetteville |
72703 |
White |
608 Rodgers Drive |
Searcy |
72143 |
Woodruff |
PO Box 493 |
Augusta |
72006 |
Yell |
PO Box 277 |
Danville |
72833 |
*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 East : 72016, 72053, 72126, 72135, 72201, 72202, 72203, 72205, 72207, 72212, 72223, 72227
Pulaski North: 72046 (England), 72113, 72114, 72115, 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)
Pulaski Southwest: 72002, 72065, 72103, 72208, 72209, 72210, 72211, 72164, 72180, 72183, 72206 (Shared with South)
DCO-0137 (R. 04/15)
