Arkansas DHS Change Report for Income and Benefits
This file provides instructions for reporting changes in household circumstances related to TEA, Medicaid, or SNAP. Use it to ensure your information is updated to receive the correct benefits. Complete the form accurately to avoid interruptions in your assistance.
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How do I fill this out?
To effectively fill out this form, gather all relevant information regarding your household changes. Make sure to complete each section accurately, as missing information may delay processing. Follow the detailed steps provided for each section to ensure a smooth submission.

How to fill out the Arkansas DHS Change Report for Income and Benefits?
1
Read the entire form to understand the requirements.
2
Gather necessary documents such as proof of income or address changes.
3
Fill in your current personal information and specifics about your case.
4
Provide detailed answers in sections according to your circumstances.
5
Submit the completed form following the provided instructions.
Who needs the Arkansas DHS Change Report for Income and Benefits?
1
Individuals receiving TEA benefits need to report any changes to their income.
2
Medicaid recipients must inform DHS of any updates to their financial situation.
3
SNAP beneficiaries who have changes in household composition must fill this form.
4
Anyone moving to a new address receiving assistance must report the change.
5
Families experiencing changes in dependents or expenses should complete this form to avoid issues in benefits.
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What are the instructions for submitting this form?
To submit this form, you may either print it and mail it to your local DHS office or send it via fax to the designated number. If you prefer, the completed form can also be emailed directly to your caseworker. Ensure that all sections are filled out completely to avoid delays. Maintain a copy for your records after submission.
What are the important dates for this form in 2024 and 2025?
While specific dates for 2024 and 2025 are not provided, it's important to stay updated with DHS announcements regarding application deadlines and reporting requirements to avoid issues with your assistance.

What is the purpose of this form?
The purpose of this form is to ensure that the Arkansas Department of Human Services has up-to-date information regarding your household circumstances. Reporting changes timely helps maintain your eligibility for benefits and ensures you receive the correct amount of assistance. It addresses financial changes, household compositions, and any other significant changes affecting your assistance programs.

Tell me about this form and its components and fields line-by-line.

- 1. Name: The individual's full name.
- 2. Budget Unit ID Number: Your assigned budget unit identification number.
- 3. Date of Birth: The date of birth of the individual.
- 4. Medicaid ID Number: Your assigned Medicaid identification number.
- 5. Current Address: Your current residential address.
- 6. New Address: If applicable, your new address when moved.
- 7. Phone Number: Your phone contact number.
- 8. Income Section: Details of any income changes.
- 9. Savings Section: Information regarding changes in liquid resources.
- 10. Household Composition: Changes in members living within the household.
- 11. Dependent Care Costs: Details on changes related to dependent care.
- 12. Medical Expenses: Changes in household members' medical expenses.
- 13. Child Support Payments: Information on any child support payments being made.
- 14. Health Coverage: Information on health coverage for household members.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or discontinuation of benefits. It is critical to keep your information current to avoid future issues with your assistance eligibility.
- Loss of Benefits: Not reporting changes can lead to a suspension of your assistance payments.
- Overpayment Issues: Incorrect information may cause overpayments that you will have to repay.
- Increased Scrutiny: Frequent discrepancies in reporting may lead to audits or additional reviews.
How do I know when to use this form?

- 1. Changed Income: Report any changes in income for you or other household members.
- 2. New Address: Indicate if you have moved to a new residence.
- 3. Added/Removed Household Members: Notify DHS if someone has moved in or out of your home.
- 4. Changes in Savings: Provide updates if your household's total savings change significantly.
- 5. Dependent Care Costs: Report any changes in costs related to dependent care to ensure accurate benefit calculation.
Frequently Asked Questions
How do I report changes to my income?
You can report changes to your income by completing the corresponding sections of the Change Report.
What details do I need to fill out the form?
You will need to include information such as your new address, income details, and any changes in household composition.
Can I edit the PDF online?
Yes, PrintFriendly allows you to edit the PDF directly on the website before downloading.
How do I send this form once completed?
You can submit the completed form via email, fax, or in person at your local DHS office.
What if I make a mistake on the form?
You can easily edit the PDF again if you notice any errors before your final submission.
Is there a deadline for submitting this form?
You should submit the form as soon as possible after any changes occur to avoid interruption of benefits.
What if my address has changed?
You must report your new address by filling out the relevant section on the form.
Can someone else fill out this form for me?
Yes, you can have a trusted person assist you in completing this form.
What happens if I don’t submit changes?
Failing to report changes may affect your eligibility for benefits.
How can I download the edited form?
After editing, click the download button to save the updated document on your device.
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