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.

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.

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.

• 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.

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.

• 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.