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SNAP CERTIFICATION MANUAL – APPENDIX A Arkansas Department of Human Services Division of County Operations DCO-110 - DCO-205 List of SNAP Forms Form Number Form Name Revision Date Use How to Access Form Form Fields DCO-110 Complaint Report Feb-18 • Used by DHS clients to make a complaint. • Records both civil rights complaints and other types of complaints. • Establishes a system for tracking complaints. DHS SHARE ONLY No DCO-128 Categorical Eligibility Test June-09 Used to determine if households are categorically eligible. DHS SHARE ONLY Yes DHS-187 Billing and Routing Sheet/ Transitional Employment Assistance Payments/ Billed to the Department of Human Services Feb-13 Used to authorize reimbursements for SNAP E&T Program participants DHS SHARE ONLY Yes DCO-191 Request for Information - Medicaid, SNAP and TEA Programs Oct-15 Used to request information when a client has applied for benefits. Used to request information postponed verification from expedited households. DHS SHARE Spanish form on DHS SHARE Order from the warehouse. Automated in ANSWER Yes DHS-199 Benefit Overpayment Report Oct-98 Used to report SNAP overpayments to the Overpayments Unit. DHS SHARE Yes DCO-201 Report of Restored Benefits Jan-95 • Used to document supervisory approval of restored benefits. • Used to report restored benefits to the Overpayments Unit. DHS SHARE ONLY No DCO-205 Employment and Training Program Referral Form & Participation Record Jun-16 • Used to refer both mandatory referrals and volunteers to the E&T contractor. • Used by the contractor as a participation record. DHS SHARE ONLY Spanish form on DHS SHARE Yes