2022 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 *12 Months* from all parents/guardians of the unborn baby who also live in the same household as the child. Items can be: One month of check stubs, tax returns, W-2s, employer statements, TEA, Social Security, SSI, WIC, SNAP, Child Support, Unemployment, Veterans Benefits, 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 County Columbia County Dallas County Ouachita County Union County
Is there a child under the age of 5 in your household?

Yes No
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

Month Day Year
Date
Race

Asian American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi-Racial Other
Hispanic

Yes No
English Proficiency

None Little Moderate Proficient
Other Language
Other Language Proficiency

Poor Moderate Proficient
Highest Grade Completed

Master's Bachelor's Associate's HS Graduate GED Grade 11 Some College Grade 10 Training Certificate Grade 9/less
If Parent is attending School, Where?
Number of hours per semester
Employment Status

Full Time Full Time & School Part Time Part Time & School Seasonal Work Training or School Unemployed Retired or Disabled
Child's Relationship

Biological/Adopt/Step Foster Grandchild Other Relative
Custody

Yes No
Check all that apply

Lives with Family Provides Financial Support Teen Parent
Primary Health Coverage

AR Kids Medicaid Private None
Medicaid # or Insurance #
How did you hear about us?

agency employee child previously enrolled family/friend internet/website radio newspaper referred by another agency sibling attended walk-in word of mouth
Is this your first time applying for the Pregnant Mom program?

Yes No
Who will be legally responsible for the child

Both Parents Mother Father Other
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

Month Day Year
Date
Race

Asiam American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi Racial Other
Hispanic

Yes No
English Proficiency

None Little Moderate Proficient
Other Language
Other Language Proficiency

Poor Moderate Proficient
Highest Grade Completed

Master's Bachelor's Associate's Some College Training Certificate High School Graduate GED Grade 11 Grade 10 Grade 9 or less
If parent is attending school, WHERE:
# of hours/semester
Employment Status

Full Time Part Time Seasonal Unemployed Full Time & School Part Time & School Training or School Retired or Disabled
Child's Relationship

Biological Foster Grandchild Other Relative
Do you have custody?

Yes No
Check all that apply

Lives with family Provides financial support Teen parent
List each additional person living in the home.
(1) Name

First Name Last Name
(1) Date of Birth

Month Day Year
Date
(1) Relationship to Child
(2) Full Name

First Name Last Name
(2) Date of Birth

Month Day Year
Date
(2) Relationship to Child
(3) Full Name

First Name Last Name
(3) Date of Birth

Month Day Year
Date
(3) Relationship to Child
(4) Full Name

First Name Last Name
(4) Date of Birth

Month Day Year
Date
(4) Relationship to Child
(5) Full Name

First Name Last Name
(5) Date of Birth

Month Day Year
Date
(5) Relationship to Child
(6) Full Name

First Name Last Name
(6) Date of Birth

Month Day Year
Date
(6) Relationship to Child
(7) Full Name

First Name Last Name
(7) Date of Birth

Month Day Year
Date
(8) Relationship to Child
(9) Full Name

First Name Last Name
(9) Date of Birth

Month Day Year
Date
Relationship to Child
(10) Full Name

First Name Last Name
(10) Date of Birth

Month Day Year
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

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

Cell Home Work
Alternate Phone Contact Name
Alternate Phone Contact Number
Please enter a valid phone number.
Alternate 2 Phone Contact Type

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

One Two
Primary Language at Home
Homeless Family

Yes No
Military Active Duty

Yes No
Military Veteran

Yes No
Referred by Child Welfare Agency

Yes No
Receiving SNAP

Yes No
Receiving WIC

Yes No
If Yes to receiving WIC, enter your WIC Household ID Number
Do you receive TANF (TEA, Work Pays, Career Pathways)

Yes No
Do you receive Supplemental Security Income

Yes No
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

Month Day Year
Date
(1) Ending Date

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

Month Day Year
Date
(2) Ending Date

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

Month Day Year
Date
(3) Ending Date

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

Month Day Year
Date
(4) Ending Date

Month Day Year
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

Social Security Disability/Death Benefits/Retirement Child Support If Yes to Child Support: Is it Weekly? If Yes to Child Support: Is it Bi Weekly? If Yes to Child Support: Is it Monthly Unemployment Benefits Scholarships, Grants Retirement Military Disability Other,
If drawing Unemployment Benefits, what date did you begin drawing?

Month Day Year
Date
MEDICAL/DISABILITY/SPECIAL NEEDS:
Do you have any pregnancy related health concerns that are being treated at this time? If yes, please describe

Yes No
If yes, please describe
Please describe any other special needs or concerns regarding your health
Expected Delivery Date

Month Day Year
Date
Expecting

Single Twins Triplets Other
What Trimester are you currently in?

1st 2nd 3rd
Are you currently enrolled in the Hannah Pregnancy Resource Center?

Yes No
Additional Family Information
Does your family have any special circumstances, concerns or needs? Such as:

Abusive home situation alcohol, drugs, child or spousal abuse Applicant is a foster child Child'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 parent Parent/guardian has no work experience or formal education (such as parenting classes, workshops or college courses) in childcare Parent/guardian is unemployed due to loss of job or being unable to work Recent death in family within last 12 months None Other Please explain
Do you have a child currently attending

Head Start ABC Other 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

Month Day Year
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