Arkansas Department Of Human Services Long Term Care Application For Assistance Page 5
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8ARKANSAS DEPARTMENT OF HUMAN SERVICES
LONG TERM CARE APPLICATION FOR ASSISTANCE
What services are you requesting?
Nursing Facility
ALF
EC
AAPD Waiver
PACE
DDS Waiver
If you need this material in a different format, such as large print contact your DHS county office.
1.
I am a resident of Arkansas:
Yes
No
I am:
65 years of age or older
Blind
Disabled
2.
3.
My full name is: _________________________________________________ Race ______ Sex ______
Last
First
Middle
My current address is:
4.
___________________________________________________________________________
Street or Route No.
City
State
Zip
County
My former address was: ___________________________________________________________________________
Street or Route No.
City
State
Zip
County
I have lived at my current address for:
_________ years.
5.
My telephone number is: _________________________
6. I
was born on: ______________________________
Month
Day
Year
7.
_____________________ ______________________
I was born in: ______________________________
Social Security Number
Medicare Number
City or County
_____________________ ______________________
_____________________________
Railroad Ret. Number
VA Claim Number
State or Country
I am a U.S. Citizen: Yes
No
9. I am a lawfully admitted Alien:
8.
Yes
No
10.
I am:
Married
Separated
Widowed
Divorced
Single
Complete Questions 11 – 15 ONLY if you have a Spouse
My spouse’s name is
11.
: ______________________________________________________________________
Last
First
Middle
My spouse’s address is:
12.
____________________________________________________________________
Street or Route No.
City
State
Zip
County
My spouse’s telephone number is
My spouse was born on:
13.
: _______________ 14.
___________________
Month
Day
Year
15.
_____________________ ______________________
___________________
_____________________
Spouse’s Soc. Sec. No
Spouse’s Medicare No.
Spouse’s Railroad Ret. No.
Spouse’s VA Claim No.
DCO-777 (R.11/07)
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