Dco-234 Change Report Form - Arkansas Department Of Human Services (Page 4 of 4) in pdf

SOCIAL SECURITY NUMBERS (SSNs)

Households must provide or apply for an SSN for each household member who will be participating in Medicaid,

, and TEA. Failure or refusal to provide for or to supply a social security number

Supplemental Nutrition Assistance Program

will result in that individual's disqualification.

PENALTY WARNINGS

Information on this form may be verified by Federal, State and

Additional SNAP Violation Penalties:



local officials through computer matching. If any information is

A court of law can ban anyone who intentionally breaks

found to be incorrect, TEA, Medicaid, and/or SNAP benefits may

SNAP rules from getting SNAP benefits for an additional 18

be denied or stopped. Also, the applicant/recipient may be

months and can impose fines of up to $25,000, or send the

subject to criminal prosecution for knowingly providing incorrect

violator to jail for up to 20 years or both.



information.

Any member of your household found to have made a

fraudulent statement or representation about their identity or

If you receive Medicaid and intentionally withhold information or

residence in order to get SNAP benefits in two locations in

misrepresent facts, you may be referred for criminal prosecution.

the same month may be disqualified for 10 years.

For TEA, your family may be disqualified from the program for 1



No individual will be eligible to receive SNAP benefits as

year after the first violation, 2 years after the second violation,

long as he or she is classified as a fleeing felon and/or a

and permanently for more than two violations.

parole or probation violator.

Any member of your household found to have intentionally

The following individuals are permanently disqualified from

broken SNAP rules will be disqualified from the Supplemental

receiving SNAP benefits:

Nutrition Assistance Program for 1 year after the first violation, 2



Violators found guilty in a court of law of buying or selling

years after the second violation and permanently after the third

firearms, ammunition, explosives, or controlled substances in

violation. The SNAP rules are:

exchange for SNAP benefits.



Do not give false information or withhold information in order



Violators found guilty in a court of law of trafficking SNAP

to get or to continue getting SNAP benefits

benefits in excess of $500.



Do not alter any authorization document to get SNAP benefits



Individuals who were found guilty of or who pled guilty or

you are not eligible to receive.

nolo contendere (no contest) to any state or federal offense



Do not use SNAP benefits to buy non-food items like alcoholic

classified as a felony by the law or jurisdiction involved, and

drinks, beer, or household supplies.

which has as an element of the offense the distribution or



Do not trade or sell SNAP benefits or allow unauthorized use of

manufacture of a controlled substance.

electronic benefit transfer (EBT) cards.



Do not use someone else's EBT card for your household's

benefit.

YOUR SIGNATURE

I understand the penalty for hiding or giving false information. I also understand I must repay extra SNAP, TEA, or Medicaid

benefits that I receive because I did not fully report changes in my household. I agree to provide verification of any reported changes

if I am asked to do so. As necessary to verify information contained in this report, I hereby authorize my employer(s), any banks,

savings and loans, lending institutions, etc., and/or Federal or State agencies to release information about me or my circumstances to

the Division of County Operations. I certify under penalty of perjury that my answers on this form are correct and complete to the

best of my knowledge and that all household members are either U.S. citizens or aliens with legal immigration status.

Do you expect the changes that you reported will remain the same next month? YES  NO 

If you answered no, please explain: ____________________________________________________________________



SIGN HERE ___________________________________________ Today's Date ___________________________

IF YOUR BENEFITS CHANGE

We will use the information you provided on this form to determine if your household's benefits must change. If we must change your

benefits, we will send you a notice explaining the action. If you do not agree with our decision, you may have a hearing to appeal the

decision. Your notice will tell you how to ask for a hearing.

CIVIL RIGHTS

The Arkansas Department of Human Services will not discriminate against any individual or group because of race, sex, religion, age,

national origin, color, marital status, disability, political affiliation, or veteran status. In accordance with Federal law and U.S.

Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex,

age, religion, political beliefs, or disability. To file a complaint of discrimination in the Supplemental Nutrition Assistance Program,

write: USDA, Director, Office of Civil Rights, Room, 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington,

D.C. 20250-9410. (Telephone and TDD for Hearing Impaired - 1-202-720-5964)

DCO-234 (rev. 12/10)

Dco-234 Change Report Form - Arkansas Department Of Human Services Page 4

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