Dco-234 Change Report Form - Arkansas Department Of Human Services
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4Arkansas Department of Human Services
Division of County Operations
CHANGE REPORT
County Office Address & Phone Number
IF YOU NEED THIS INFORMATION IN A DIFFERENT FORMAT
SUCH AS LARGE PRINT, CONTACT THE DHS COUNTY OFFICE.
(Si necesita este formulario en Español, llame al 1-800-482-8988 y pida la
versión en Español.)
You may call or email the DHS County Office at the phone number or
webmail address shown to report changes for your TEA, Medicaid, or SNAP case(s). Please use the toll-free number
provided if the DHS County Office number is long distance.
Name: ________________________________ Your Social Security Number: ________________________
Check all that you receive:
TEA
Medicaid
SNAP
Enter your
_______________________________
Phone # __________________________________
Address:
_______________________________
Hearing Impaired Phone # __________________
_______________________________
E-mail address ____________________________
Is this a new address?
YES
NO
NOTE: If you have moved, you must complete Section 5.
If your address changes, you should report your new address to us at once or you may not receive important
correspondence from DHS.
INSTRUCTIONS: You may use this form to report the following changes in your household's circumstances.
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
TEA AND MEDICAID PROGRAMS ONLY
ONLY:
You must report any change in income you receive
You must report changes in your total household
regardless of the amount received or how often you
income when it goes up or down by more than $50
expect to receive it.
per month. (You do not have to report changes in
For Medicaid, you must report increases in your
your TEA benefit amount.)
household's savings if the total amounts to $1,000 or
You must report increases in your household's cash
more.
and savings if the total cash and savings of all
For TEA Cash Assistance, you must report increases
household members now equal or exceed $2,000 or
in your household's savings if the total amount
more.
exceeds $3,000.
The following changes must be reported in the following Programs: SNAP, Medicaid and TEA Cash Assistance
You must report changes in any source of income.
You must report if you move to a new residence.
You must report cars, or other licensed vehicles if
If you move, you must report your new rent (or
anyone in your home get one.
mortgage) and utility costs.
You must report changes in the number of people in
You should always report any address changes even if
your household.
you do not move.
NOTICE TO SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM HOUSEHOLDS SUBJECT TO
SEMI-ANNUAL REPORTING AND/OR LIMITED REPORTING: See the ADDENDUM for an explanation of
your reporting requirements. You may use this Change Report to report if your income begins to exceed the limit for
your household size or if certain people in your home begin working less than 20 hours per week. Those are the changes
that you are required to report. However, you may use this form to report a change if you would like to do so. YOU OR
ANYONE IN YOUR HOME WHO GETS CASH ASSISTANCE OR MEDICAID MUST CONTINUE TO REPORT
CHANGES AS SHOWN ABOVE. IF THESE CHANGES AFFECT YOUR SNAP CASE, WE WILL LET YOU
KNOW.
DCO-234 (rev. 12/10)
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