FACT, Inc Pregnant Mom Application

Pregnant Mom Application
ATTACHMENTS ARE REQUIRED TO SUBMIT THIS FORM

If you do not have any income, upload a statement stating so and you will be contacted for other needed documents.
1. Household income verification for the past twelve months. Household income includes all means of support for the last twelve months from all parents/guardians of the unborn baby who also live in the same household as the child. One month of check stubs, tax returns, W-2s, employer statements, TEA, SSI, WIC, SNAP, Unemployment, etc.*

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Please provide a copy of your Medicaid card, AR Kids card, or Private Insurance card if you have one. Medicaid applications are available upon request.

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Please Indicate below where you would like to be placed. Home Based Options:

Calhoun CountyColumbia CountyDallas CountyOuachita CountyUnion County
Is there a child under the age of 5 in your household?

YesNo
If yes, please also complete a Child Application
F.A.C.T., Inc. takes many factors into consideration in order to determine eligibility. In addition to your income level and the age of your child, other child and family needs are noted. The following information will be used to help determine eligibility and for us to become familiar with your family. Applications are evaluated on a points system and those with the highest points are selected first.
Mother's Information

All of the following questions are related to the mother.
E mail address
example@example.com
First Name
Middle Name
Last Name
Date of Birth

MonthDayYear
Date
Race

AsianAmerican Indian/Alaska NativeBlackHawaiian/Pacific IslanderWhiteMulti-RacialOther
Hispanic

YesNo
English Proficiency

NoneLittleModerateProficient
Other Language
Other Language Proficiency

PoorModerateProficient
Highest Grade Completed

Master'sBachelor'sAssociate'sHS GraduateGEDGrade 11Some CollegeGrade 10Training CertificateGrade 9/less
If Parent is attending School, Where?
Number of hours per semester
Employment Status

Full TimeFull Time & SchoolPart TimePart Time & SchoolSeasonal WorkTraining or SchoolUnemployedRetired or Disabled
Child's Relationship

Biological/Adopt/StepFosterGrandchildOther Relative
Custody

YesNo
Check all that apply

Lives with FamilyProvides Financial SupportTeen Parent
Primary Health Coverage

AR KidsMedicaidPrivateNone
Medicaid # or Insurance #
How did you hear about us?

agency employeechild previously enrolledfamily/friendinternet/websiteradionewspaperreferred by another agencysibling attendedwalk-inword of mouth
Is this your first time applying for the Pregnant Mom program?

YesNo
Who will be legally responsible for the child

Both ParentsMotherFatherOther
Father's Information

Only Complete this section if the father is in the household
E mail address
example@example.com
First Name
Middle Name
Last Name
Jr, Sr., II, III
Date of Birth

MonthDayYear
Date
Race

AsiamAmerican Indian/Alaska NativeBlackHawaiian/Pacific IslanderWhiteMulti RacialOther
Hispanic

YesNo
English Proficiency

NoneLittleModerateProficient
Other Language
Other Language Proficiency

PoorModerateProficient
Highest Grade Completed

Master'sBachelor'sAssociate'sSome CollegeTraining CertificateHigh School GraduateGEDGrade 11Grade 10Grade 9 or less
If parent is attending school, WHERE:
# of hours/semester
Employment Status

Full TimePart TimeSeasonalUnemployedFull Time & SchoolPart Time & SchoolTraining or SchoolRetired or Disabled
Child's Relationship

BiologicalFosterGrandchildOther Relative
Do you have custody?

YesNo
Check all that apply

Lives with familyProvides financial supportTeen parent
List each additional person living in the home.
(1) Name

First NameLast Name
(1) Date of Birth

MonthDayYear
Date
(1) Relationship to Child
(2) Full Name

First NameLast Name
(2) Date of Birth

MonthDayYear
Date
(2) Relationship to Child
(3) Full Name

First NameLast Name
(3) Date of Birth

MonthDayYear
Date
(3) Relationship to Child
(4) Full Name

First NameLast Name
(4) Date of Birth

MonthDayYear
Date
(4) Relationship to Child
(5) Full Name

First NameLast Name
(5) Date of Birth

MonthDayYear
Date
(5) Relationship to Child
(6) Full Name

First NameLast Name
(6) Date of Birth

MonthDayYear
Date
(6) Relationship to Child
(7) Full Name

First NameLast Name
(7) Date of Birth

MonthDayYear
Date
(8) Relationship to Child
(9) Full Name

First NameLast Name
(9) Date of Birth

MonthDayYear
Date
Relationship to Child
(10) Full Name

First NameLast Name
(10) Date of Birth

MonthDayYear
Date
(10) Relationship to Child
Family Information
Living Address
Address Line 2
Zip Code
State
County
Mailing Address
Mailing Address Line 2
Mailing Zip Code
Mailing City
Mailing State
Mailing City
Mailing County
Mother's Phone Number Contact Type

CellHomeWork
Mother's Name
Mother's Phone Number
Please enter a valid phone number.
Alternate Phone Contact Type

CellHomeWork
Alternate Phone Contact Name
Alternate Phone Contact Number
Please enter a valid phone number.
Alternate 2 Phone Contact Type

CellHomeWork
Alternate 2 Phone Contact Name
Alternate 2 Phone Contact Number
Please enter a valid phone number.
Parental Status (check one)

OneTwo
Primary Language at Home
Homeless Family

YesNo
Military Active Duty

YesNo
Military Veteran

YesNo
Referred by Child Welfare Agency

YesNo
Employment Information

List employment history for the last 12 Months for both parent(s) and/or all guardian(s) of the unborn baby. You must list ALL places of employment and proof of income must be provided for each (proof of income submission was at the top of this form)
(1) Parent Name
(1) Employer
(1) Work Address
(1) Work Phone Number
Please enter a valid phone number.
(1) Beginning Date

MonthDayYear
Date
(1) Ending Date

MonthDayYear
Date
(2) Parent Name
(2) Employer
(2) Work Address
(2) Work Phone Number
Please enter a valid phone number.
(2) Beginning Date

MonthDayYear
Date
(2) Ending Date

MonthDayYear
Date
(3) Parent Name
(3) Employer
(3) Work Address
(3) Work Phone Number
Please enter a valid phone number.
(3) Beginning Date

MonthDayYear
Date
(3) Ending Date

MonthDayYear
Date
(4) Parent Name
(4) Employer
(4) Work Address
(4) Work Phone Number
Please enter a valid phone number.
(4) Beginning Date

MonthDayYear
Date
(4) Ending Date

MonthDayYear
Date
OTHER INCOME/PUBLIC ASSISTANCE:

If a household member receives, or has received any of the following during the last 12 Months: Proof must be provided with this application. Submission portal is at the top of this application. Please check all boxes that apply.
Monthly

SNAP (food stamps)Supplemental Security Income (SSI)TANF (TEA, Work Pays, Career Pathways)Unemployment Benefits, Date Began DrawingWIC
If drawing Unemployment Benefits, what date did you begin drawing?

MonthDayYear
Date
If Yes to receiving WIC, enter your WIC Household ID Number
MEDICAL/DISABILITY/SPECIAL NEEDS:
Do you have any pregnancy related health concerns that are being treated at this time?

YesNo
If yes, please describe
Please describe any other special needs or concerns regarding your health
Expected Delivery Date

MonthDayYear
Date
Expecting

SingleTwinsTripletsOther
What Trimester are you currently in?

1st2nd3rd
Are you currently enrolled in the Hannah Pregnancy Resource Center?

YesNo
Additional Family Information
Does your family have any special circumstances, concerns or needs? Such as:

Abusive home situation alcohol, drugs, child or spousal abuseApplicant is a foster childChild's parent is currently incarcerated (in prison/jail)Current address is a temporary living arrangement due to loss of housing or economic hardship. (You will be contacted to fill out a Residency Questionnaire)First time parentParent/guardian has no work experience or formal education (such as parenting classes, workshops or college courses) in childcareParent/guardian is unemployed due to loss of job or being unable to workRecent death in family within last 12 monthsNoneOther Please explain
Do you have a child currently attending

Head StartABCOther Preschool Program
If yes, where?
Are you related to a staff member of F.A.C.T., Inc. If so, please state who and what the relationship is
This information will only be used for placement if you are selected for enrollment. Icertify that the above information is true. I understand that if any information is found to be false, my family's participation in this Agency's programs may be terminated, and that I may be subject to legal action. I also understand that this information is confidential and is accessible to me during normal business hours.
Signature of Parent/Legal Guardian

Clear
Printed Name of Parent/Legal Guardian
Date

MonthDayYear
Date
Should be Empty:

Pregnant Mom Application

If yes, please also complete a Child Application

Mother's Information

Father's Information

List each additional person living in the home.

Family Information

Employment Information

OTHER INCOME/PUBLIC ASSISTANCE:

MEDICAL/DISABILITY/SPECIAL NEEDS:

Additional Family Information