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THIS FORM MUST BE COMPLETED BY YOUR EMPLOYER AND RETURNED TO THE ADDRESS AT THE RIGHT WITHIN 10 BUSINESS DAYS.

Jan 1, 2003 · Applicants who are paid once per month must submit two pay stubs that are 90 or fewer days old from the date a child care form is received (application, redetermination, change of information) to verify earnings.

Search Forms by Name/Number - in the "Form" field enter all or part of the form name or number. by Division - choose the desired division from the "Division" field.

Apr 1, 2025 · Income Trust Form: PDF: 01/01/2025: Income Trust Fact Sheet: PDF: 07/01/2022: Your Guide To Medicaid Estate Recovery In Arkansas: PDF: 01/30/2018: SNAP Forms & Documents. Title ... Employment Verification; DHS Policies; Facebook Twitter Youtube Instagram. Contact Us. Divisions & Offices: Donaghey Plaza, P.O. Box 1437, Little Rock, AR 72203.

section 3 - income information Employer: Please complete the following information about each pay received during the period specified below. (Use additional paper or computer printout if necessary.)

Arkansas Department of Human Services Verification of Earnings TO EMPLOYER: To determine eligibility and correct benefits for your employee we need the information requested below. This will enable us to ensure that the public funds are used only for the actual and correct benefits to which a household is entitled.

DHS-FIA 500 Medical Report Form. 0500-B Verification of Activity Participation Form.pdf

If using a mobile device to complete any of these forms, you may need to download a free PDF reader. Family Assistance Applications Apply for Families First and/or SNAP online

Department of Human Services Employment and Income Verification IL444-4831 (N-10-10) Page 1 of 1 Issued by: Date: Permission Statement I authorize my employer to release the following requested information to: ... RETURN COMPLETED FORM TO Address: Phone Number: Fax Number: G. 26"!

Send completed form to OHR via fax to 501-682-6553, via e-mail [email protected] or via mail to OHR – Recruitment; PO Box 1437, SLOT W301, Little Rock, AR 72201-1437. I am a: Current Employee