Apply for Benefits
Application ID: T101419225 Submission Date and Time: 2024-05-05 15:05:24.672
Application Received Date: 05/06/2024 Program(s) applied: Health Care, Supplemental Nutrition
Assistance Program (SNAP)
Specialty Categories:
Person filling out this form
I'm filling out this form for: Myself or people I live with Are you the authorized representative for the person
applying for benefits?
Language for letters and forms we send you: English
Authorized representative
Do you want to give someone the right to act for you - to be your authorized representative? NO
First name: Middle name or initial: Last name:
Primary phone number: Alternative phone number:
Work phone number: Work phone number extension:
E-mail address:
Organization name: Organization ID number:
This person is your:
Certified application counselor, navigator or assister
Is a certified application counselor, navigator, or assistor helping you apply for benefits? NO
First name: Middle name or initial: Last name:
Organization name: Organization ID number:
Phone number:
Expedited screening
Is anyone in the home a migrant or seasonal farm worker? Total monthly income (before deductions): $0.00
NO
Total liquid resources (cash, checking, savings, etc.): Does anyone in the home How much? $0.00
$0.00 pay costs for
rent/mortgage?
Does anyone in the home pay costs for utilities? Which utilities?
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Interview details
Do you need a language interpreter (for this interview)? What language?
NO
Would you like a telephone or face to face interview? Will you need special help or equipment if you come into
Telephone our office for an interview? NO
What special help or equipment will you need? Phone number to call for Would you like to schedule
interview: 4702180547 an interview now? NO
Interview location: Date of interview: Interview time:
Household information
Contact person or head of household
First name: Michael Middle name or Last name: Franklin
initial: I
Suffix: Sex: Male Date of birth: 04/13/2002
Social Security number: 675140910
Homeless/Home address not available? YES
Home address (Street Number, Street Name, P.O. Box): Home Address(Apartment/Suite/Building):
City: little rock State: Arkansas Zip: 72209
Is your mailing address different than your home address?
Mailing address (Street Number, Street Name, P.O. Box): 10223 Mailing Address (Apartment/Suite/Building):
Independence Ln
City: Little Rock State: Arkansas Zip: 72209
Contact information
Primary phone number: 4702180547 Alternative phone number:
Work phone number: Work phone number extension:
Do you want to receive paperless notices for Alerts preference: Email alerts, Text message alerts
your case? YES
E-mail address: [email protected] Cell phone number: 4702180547
Information about people in your home
Does anyone applying for benefits have a Is anyone in your home pregnant or has anyone been pregnant in
disability? YES the last 3 months? NO
Does anyone in the home receive rent subsidy? Does anyone in the home live in public housing? NO
NO
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Person details - Michael Franklin 04/13/2002
Prefix: First name: Michael Middle name: I
Last name: Franklin Suffix: Sex: Male Date of birth: 04/13/2002
Is this person applying for benefits? YES Does this person have a Social Security
Number? YES
Has this person applied for a Social Security number? Reason for not applying for Social Security
number:
Social Security number: 675140910
Marital status: Single (Never Married) Program(s) applied: Health Care,
Supplemental Nutrition Assistance Program
(SNAP)
Is the person deceased? NO Date of Death: Does the person have a parent living outside
the home?
Alert settings
Alerts preference: Email alerts, Text message alerts
E-mail address: [email protected] Cell or daytime phone: 4702180547
Race and ethnicity
Is this person an American Indian or Alaskan Native? NO Ethnicity: Non-Hispanic or Latino
What is this person's race? Black or African-American
Is this person a member of a Name of tribe: State of the tribe: Tribe ID:
federally recognized tribe?
Has this person ever received a service from the Indian Health Service, a tribal program, or the urban Indian health
program or through a referral from one of these programs?
Is this person eligible to receive services from the Indian Health Service, a tribal program, or the urban Indian health
program or through a referral from one of these programs?
Residence and citizenship
Does this person live and intend to stay in Arkansas? YES Is this person a U.S. citizen or a U.S. National? YES
Sponsor first name: Sponsor last name:
Is sponsor receiving SNAP (Supplemental Nutrition Assistance Program ), TEA (Transitional Employment Assistance),
or SSI (Supplemental Security Income)?
Alien number: Alien/Immigration Status:
Type of immigration document this person has: Document ID:
Document expiration date: Initial date of entry:
Foster care details
Was this person ever in foster care? NO State:
How old was this person when he/she left the foster care system? Was this person enrolled in Medicaid at
that time?
Living arrangement
Where does this person live? Homeless Does this person pay for meals and lodging? YES
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Other details
Does this person need help with daily living activities? Is this person disabled? YES
YES
Is this person acting as a specified caretaker relative?
Is this person an emancipated minor? NO Type of emancipation: Date of emancipation:
Is this person planning to live in a Nursing Home in the next 15 days? NO
Is this person a fleeing felon or probation/parole violator? NO
Is this person a veteran or has served in the military/US If yes, which?
armed forces? NO
Register to vote
Would this person like to apply to register to vote here today? NO
Disability - Michael Franklin 04/13/2002
Type of disability: Physical Short-term or Long-term? Long-term
Education - Michael Franklin 04/13/2002
Is this person going to school? NO
Education details
Does this person attend school full-time? How many hours?
Frequency: School/Organization Name:
Type of school: Date this person plans to graduate:
Address (Street Number, Street Name, P.O. Box): Address (Apartment/Suite/Building):
City: State: Zip:
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Absent parent - Michael Franklin 04/13/2002
Absent parent details
Sex: Why is this parent absent from the home?
Do you know the name of the absent parent?
First name: Last name:
Social Security number:
Birth date: Cell or daytime phone:
Address (Street Number, Street Name, P.O. Box): Address (Apartment/Suite/Building):
City: State: Zip:
Address Line 1: Address Line 2:
Address Line 3: APO/FPO: AA/AE/AP: Zip:
You may claim good cause to not cooperate with the Office of Child Support Enforcement if you believe that it would
not be in the best interest of you or the child. You may have to provide proof to support your claim of good cause.
Would you like to claim good cause to not cooperate with the Office of Child Support Enforcement?
Good Cause Reason:
Earned income (Job) - Michael Franklin 04/13/2002
Employer Name/Source of Income: Start date at this job:
Last date of employment: Still working at this job? Reason for leaving:
Does this person pay for certain things that can be deducted on an income tax return?
Wages
Does this person receive money through a contract?
Hourly rate: How many hours worked in a week:
Gross pay (before taxes and other deductions):
How often received?
Employer details
Employer identification number:
Employer Address (Street Number, Street Name, P.O. Employer Address (Apartment/Suite/Building):
Box):
City: State: Zip:
Employer's phone number:
Earned income (Self-employment) - Michael Franklin 04/13/2002
Type of Income: Employer Name/Source of Income:
Start date at this job:
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Money from this job
Has this person filed taxes on this self employment?
Gross annual income from tax return: Net annual profit from tax return:
Average monthly income: Hours worked per week:
Does this person expect this income next year? Has this person's business been running for more than one
year?
Expenses and deductions from this job
Does this person have business expenses for this job? Average monthly expenses:
Examples: taxes, rent, insurance, supplies, gas, etc.
Does this person pay for certain things that can be deducted on an income tax return?
Other money sources - Michael Franklin 04/13/2002
Did this person get other money in the last 3 months (not from a job)? NO
Type of money: Type of payment:
Name of the person, company, or agency paying this money:
Does this person receive money through a contract?
Claim number (if it applies): Amount paid:
How often paid? Most recent pay date:
Account - Michael Franklin 04/13/2002
Is this person an owner of, co-owner of, or an authorized signer on any of the following: cash on hand, bank accounts,
savings bonds, stocks, mutual funds, or other accounts? YES
Account details
Type of cash, loan, or account: Checking Account
Name of bank, business, or person to contact about this cash, loan, or account: Wells Fargo
Account number: 7260319731 Total value: $1.46 Deposit Date:
Address of bank or company (Street Number, Street Address of bank or company (Apartment/Suite/Building):
Name, P.O. Box): N/A
City: State: Georgia Zip:
Co-owner's details
Is there more than one person listed as an owner (a co-owner)? NO
Vehicle - Michael Franklin 04/13/2002
Does Michael Franklin own or is Michael Franklin paying for a: All-terrain(ATV), Boat, Camper/RV, Car, Farm
equipment, Motorcycle, Trailer, Truck, Other? NO
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Property - Michael Franklin 04/13/2002
Does this person own or share ownership in a home, land, or other properties, including mobile homes? NO
Does this person have a life estate or remainder interest in property?
Trust - Michael Franklin 04/13/2002
Does this person have any trusts? NO
Burial arrangement - Michael Franklin 04/13/2002
Does this person have any burial or funeral arrangement? NO
Life insurance - Michael Franklin 04/13/2002
Does this person have life insurance? NO
Other items - Michael Franklin 04/13/2002
Does this person have any other items that they are paying for, own, or share ownership? NO
Past income - Michael Franklin 04/13/2002
Other state benefit details
Is this person getting cash assistance, food, or health care benefits from another state?
Resources - Michael Franklin 04/13/2002
Livestock
Total number of livestock (cows, horses, pigs, etc.): 0 Total value: $0.00
Poultry
Total number of poultry (chickens, ducks, geese, etc.): 0 Total value: $0.00
Cost to take care of others - Michael Franklin 04/13/2002
Does this person pay for adult care?
Does this person pay alimony or spousal support?
Does this person pay for child care?
Does this person pay child support?
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Insurance and bills - Michael Franklin 04/13/2002
Does this person get Medicare? NO
Does this person have any health insurance? NO
Does this person have any paid or unpaid medical bills? YES
Did this person lose health insurance? YES
Medical bills details
Is this bill from services in the past three months? NO Type of bill: Attendant Care Is this bill from a medical
emergency?
Was this person's household size the same during the What was the household size during those 3 months?
last 3 months as it is now? NO
Was this person's average household income the same What was the average household income during those 3
during the last 3 months as it is now? months?
Amount paid: $0.00 Amount unpaid: $222.00 Bill status: Unpaid
Paid for someone else
Was this bill paid for someone else? NO
Medical bills details
Is this bill from services in the past three months? NO Type of bill: Transportation for Is this bill from a medical
medical emergency?
Was this person's household size the same during the What was the household size during those 3 months?
last 3 months as it is now? NO
Was this person's average household income the same What was the average household income during those 3
during the last 3 months as it is now? months?
Amount paid: $0.00 Amount unpaid: $4319.00 Bill status: Unpaid
Paid for someone else
Was this bill paid for someone else? NO
Tax filing information - Michael Franklin 04/13/2002
Does this person plan to file a federal income tax return next year? NO
Will this person file taxes with a spouse?
Spouse's first name: Spouse's last name:
Will this person claim any dependents on their tax return? Will someone claim this person on their tax return?
Statement of Understanding
All Benefit Programs
Information Arkansas Department of Human Services (DHS) has about me
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DHS collects information from you including, but not limited to, name, address and social security
number. DHS uses information about people applying for benefits to decide: (1) who can get
benefits and (2) the amount of benefits. DHS checks information with the Federal Income and
Eligibility Verification System. If any information does not match, DHS will check other sources
(banks, employers, etc.). If anyone applying for benefits has an immigration registration number,
DHS must check with the U.S. Citizenship and Immigration Services' (USCIS) system. DHS will not
give anyone's information to USCIS. I understand and agree that DHS and other federal agencies
may check the information I give to DHS, and the information DHS learns about me may affect
whether I can get benefits.
DHS may share your information with other state agencies, the Federal government, companies
hired by DHS to help process your information, and people and organizations who provide services
to you.
DHS will protect your information using appropriate technology following state and Federal law.
DHS will maintain your information using information from you, other state agencies, and the
Federal government. DHS will keep your information for up to 10 years. At the end of that time, your
information will be safely disposed of following state and Federal law.
You may update or remove your information by logging onto this system or by contacting your local
DHS office.
I declare under penalty of perjury that to the best of my knowledge I, or the person I am applying
for, is a U.S. citizen or is lawfully present in the United States. All the information provided in this
form is true to the best of my knowledge. If any information I give is untrue or incorrect, my benefits
may be reduced or denied, and I could be prosecuted for a crime and be unable to receive benefits
in the future.
Information anyone tells or gives DHS
DHS uses the information anyone tells or gives DHS, including Social Security numbers (SSN) to:
• Check if that person can get benefits by contacting financial institutions, employers, and
others
• Check that person's information with computer matching programs and credit reporting
agencies
• Make sure that person is following benefit program rules
• Help other agencies check if that person can get other benefits
• Recover the cost of benefits that person was not supposed to get
• Share information about that person: (1) with other State and Federal agencies (for example,
the Arkansas Department of Workforce Services, the Social Security Administration and the
Internal Revenue Service); (2) with law enforcement officials so they can find people on that
person's benefits case (the household) who are wanted for fleeing the law; and (3) with
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Federal, State and private claims collecting agencies for food benefit overpayment claims
collection action
This is allowed under federal laws and regulations, including: 42 U.S.C. §§ 1320b-7(a) (1) and
1320b-7(b) (2); The Food and Nutrition Act of 2008, 7 U.S.C. § 2011-2036, 7. C.F.R. § 273.2, 45
C.F.R. § 205.52, 42 C.F.R. § 435.910, and 42 C.F.R. § 435.920.
Right to Appeal
If you think that DHS has made a mistake, you can appeal its decision. To appeal means to tell
someone at DHS that you think the action was wrong and you can ask for a fair review of the
action.
You can find out how to appeal by contacting your local DHS office or the Office of Appeals and
Hearings at 501-682-8622. Also, you can be represented in the process by someone other than
yourself. Your eligibility and other important information will be explained to you.
Health care (Medicaid)
If I give untrue information
If I choose not to tell the truth, I might:
• Be charged with a crime
• Have to repay the cost of benefits
The same is true if I let someone else use my medical card or Medicaid ID.
Giving out information about me
I agree to let Medicaid health care providers (doctors, drug stores, hospitals, etc.) give out any
information about me to DHS. This will let the providers be paid by Medicaid.
Medical and child support payments
Depending on my case, the State might check that I am getting the right amount of child or medical
support payments and coverage.
• If my child and I both get Medicaid, I must:
o Help the state get any payments and coverage we should get, but don't get right now. If I
don't help the state, my child can get Medicaid, but I might not
o Identify who the child's other parent is
o Allow the state to keep any medical support payments in a child support case
If I get Medicaid, DHS will keep medical services payments I can get from other sources, such as:
• My health insurance
• Money I got in a lawsuit or settlement because of injuries
• Money collected for me or my children by the Office of Attorney General
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I must tell DHS about these sources. If I don't, I am breaking the law. DHS will only keep the
amount of medical support and service payments allowed by law. I will work with DHS to get these
funds.
Estate recovery for health care benefits
I understand that if I get health care benefits while I am in a nursing home, intermediate care or
other inpatient facility, or receiving home- and community-based services:
• The health care benefits I get will be a debt to DHS that can be recovered from the property I
own after my death, which is known as my estate
• The debt may also be recovered from the grantee of a beneficiary deed after my death.
• DHS will not make a claim against my estate while I am living
• DHS will not make a claim against my estate if my spouse is still living or if I have dependent
children under age 21, a child who is blind, or a child with disabilities
If DHS wants to collect the debt, it will file a claim with my estate. DHS may choose not to collect
the debt if it is not cost-effective or if my heirs apply for and are granted a hardship waiver.
Asset Verification Consent
I know that my signature below, on the application, or both lets DHS get information about things I
own (including money) from banks, credit unions, or other financial institutions, so DHS can decide
if I can get benefits. DHS can keep checking this information until:
• DHS denies my application for health care; or
• I can't get health care anymore; or
• I tell DHS in writing that I do not want DHS to check this information any more.
Arkansas Works
I understand that:
• The Arkansas Works program is not a perpetual federal or state right or a guaranteed
entitlement program and that my benefits may end at any time upon appropriate notice
• If I am eligible for the Arkansas Works Medicaid program, my information will be shared with
the Arkansas Department of Workforce Services (DWS)
• Participation with DWS will not affect my eligibility for health care benefits or the Arkansas
Works Medicaid program.
• I may have to pay money each month to have health care coverage. If I do not pay that
amount each month, I will owe the state
Cash Help for Families (TEA)
Child support
I agree to:
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• Let the state keep any child support money owed to anyone during the time they get TEA
• Let the state keep this money after TEA benefits end, if the TEA amount anyone got still
needs to be paid off
• Tell DHS about money anyone gets in my household
• TEA applicants/recipients with children under 18 living in the home shall be required to
cooperate with the Office of Child Support Enforcement. Good cause exceptions may apply.
The state will keep only the amount allowed by law.
If I give untrue information or do not follow program rules
If I choose not to tell the truth or follow program rules for TEA, I might:
• Be charged with and punished for a crime (this could include going to prison for up to 10
years or community supervision)
• Have to repay the cost of benefits
• Never get TEA again
A full list of program penalties can be found here.
Food Benefits (SNAP)
Telling the truth
Anyone who applies for or gets SNAP must:
• Tell the truth
• Never trade or sell SNAP benefits, EBT cards, or other devices that allow people to get
SNAP
• Never use or have EBT cards or other devices that don't belong to them
Anyone who chooses not to tell the truth or follow program rules might:
• Not get SNAP for a year or more
• Be fined up to $250,000, jailed up to 20 years, or both
• Lose income tax refunds
• Be charged with other crimes
• Have to repay the cost of benefits
• Never get SNAP again
The same is true if anyone lets someone else use their EBT card. A full list of program penalties
can be found here.
Disqualifications
Individuals found to have committed an Intentional Program violation either through an
administrative disqualification hearing or by a Federal, State, or local court, or who have signed a
waiver of right to an administrative hearing or a disqualification consent agreement in cases
referred for prosecution shall be ineligible to get SNAP benefits for a period of one year for the first
violation; two years for the second violation; permanently for the third violation. Individuals found by
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a Federal, State, or local court to have used or received benefits in a transaction involving the sale
of a controlled substance shall (as defined in section 102 of the Controlled Substance Act (21
U.S.C. 802) shall be ineligible to participate in the program for a period of two years for the first
violation; permanently for the second violation. Individuals found by a Federal, State, or local court
to have used or received benefits in a transaction involving the sale of firearms, ammunition or
explosives shall be permanently ineligible to participate in the Program upon the first occasion of
such violation. An individual convicted by a Federal, State, or local court of having trafficked
benefits for an aggregate amount of $500 or more shall be permanently ineligible to participate in
the Program upon the first occasion of such violation. An individual found to have made a
fraudulent statement or representation with respect to the identity or place of residence of the
individual in order to receive multiple SNAP benefits simultaneously shall be ineligible to participate
in the Program for a period of 10 years. A person who is a fleeing felon or a parole or probation
violator is barred from getting SNAP while they are fleeing to avoid custody.
Requirement to Work
I understand that if I am 18-49 years old, I must meet the requirement to work (RTW) rule, unless I
have an exemption. If I am required to meet the rule but do not, I can only receive SNAP benefits
for three months in a three-year period. If I meet the requirement, my benefits can continue.
Cooperation with Child Support Enforcement
SNAP applicants/recipients with children under 18 shall be required to cooperate with the Office of
Child Support Enforcement. This includes parents living in the home and out of the home. Good
cause exceptions may apply.
Child Care Assistance
1. All adults in the Low-Income Eligibility group must:
• Work thirty (30) or more hours per week or,
• Attend school full time or job skills training program equal to thirty (30) hours per week
or,
• Combine work and school/job skills training to equal thirty (30) or more hours per week
At least one adult in the ESS group must:
• In first 12 months: Work at least twenty- (20) hours per week, or your earnings must be
enough to cause you to be ineligible for TEA cash assistance.
• In second 12 months: Work twenty-five (25) or more hours per week.
2. Lifetime limit for Low Income child care assistance is sixty (60) months per parent/custodian
unless otherwise exempted. ESS Lifetime limit is 24 months.
• Any month in which five (5) days are billed by CCDF Program Participant (child care
provider) is considered a month of child care assistance and countable towards the
lifetime limit.
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3. DHS will not retroactively pay or reimburse Low Income child care expenses prior to
approval.
4. CCDF Program Participant (child care provider) may be selected according to parental
choice. CCDF Program Participant information may be found on our website:
https://humanservices.arkansas.gov/divisions-shared-services/child-care-early-childhood-ed
ucation/access-arkansas-ccdf-home/
Website information includes:
• Child care search tool
• Facility complaints
• Better Beginnings rating
• Facility visits
5. No child, receiving subsidy funding, shall be suspended or expelled from the facility without
approval from DCCECE. https://www.behaviorhelponline.org/
6. Once eligibility is determined, Low Income applicants must complete an initial interview with
a Family Support Specialist (FSS). Low Income redetermination interviews shall be
completed based on the Better Beginnings Level. Better Beginnings Level one (1) and two
(2) are once a year. Better Beginnings Level three (3) are every two years.
7. The CCDF Program Participant (child care provider) may charge the following fees:
• Co-pay based on Better Beginnings Rating.
• Registration, late pickup, late payment, insurance, materials or reasonable fees
• Fees for exceeded absentee days
• Additional charges may apply if child care provider is a Better Beginnings Level two (2)
or higher
Days
Trimester Allowed Not to Exceed
6 in a given
July - October 12 month
November - 8 in a given
February 16 month
6 in a given
March - June 12 month
8. All notices will be sent electronically via email. An accurate and valid email address must be
on file. Email should be checked regularly to ensure all notices are received. DHS is not
responsible for any lapse of communication for failure to report an email change within ten
(10) calendar days of the change.
9. The following changes must be reported to your Family Support Specialist (FSS) within ten
(10) calendar days of the change: Address, email, phone number, change of CCDF Program
Participant, income over eighty-five (85%) SMI, household composition that increases
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household income over eighty-five (85%) SMI. Any cessation of work, and/or attendance at
education or training program must be reported within ten (10) calendar days.
Monthly Exceeded Income
Family Size Income Limit
1 2259.68 2259.69
2 2954.97 2954.98
3 3650.76 3650.77
4 4345.54 4345.55
5 5040.83 5040.84
6 5736.12 5736.13
10. A change of CCDF Program Participant (child care provider) may require a redetermination
of eligibility. Payments to the new provider are your responsibility until the change is
processed. A child care arrangement form and change report form are required ten (10)
calendar days prior to the day of change.
11. If any adverse action is taken on your application or child care case, excluding overpayment
or fraud, you have the right to an Internal Review. If an overpayment, fraud, and/or
Intentional Program Violation is alleged, you have the right to an Administrative Hearing.
12. Families declaring assets in excess of $1,000,000 are ineligible for Subsidized Child Care
Assistance. At the time of initial application and redetermination, families will be asked to
declare if they have assets in excess of $1,000,000.
USDA Nondiscrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions
participating in or administering USDA programs are prohibited from discriminating based on race,
color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation
for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information
(e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency
(State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have
speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or
write a letter addressed to USDA and provide in the letter all of the information requested in the
form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or
letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
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(2) fax: (202) 690-7442; or
This institution is an equal opportunity provider.
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues,
persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in
Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers
by State); found online at: SNAP Hotline.
To file a complaint of discrimination regarding a program receiving federal financial assistance
through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for
Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202)
619-0403 (voice) or (800)537-7697(TTY).
Signature declaration
By signing below, I agree:
To assign to the State all rights to medical support and to payment for medical care from any third party (hospital and
medical benefits).
To cooperate with the state in identifying and providing information to assist the state in pursuing any third party who
may be liable to pay for care and services.
That I must report any payments received for medical care within ten days
To give the State the right to require an absent parent to provide medical insurance, if available.
That I must get medical support from the absent parent if it is available and must cooperate with the Office of Child
Support Enforcement (OCSE) in obtaining this support. If I do not cooperate, I understand I may lose my Medicaid
benefits, and only my child(ren) will receive benefits unless good cause is established.
By checking the box on the online application I verify that: I am authorized to electronically sign this application as the
parent, guardian, or authorized representative of the individuals included in this application. I understand that any false
information submitted in this application may result in disqualification of my application and/or criminal or civil penalties
imposed against me.
First name: Michael Last name: Franklin Date: 05/05/2024
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