Form Faa-1562a - Nutrition Assistance Drug Testing Agreement
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-1565A FORFF (7 -17)
Family Assistance Administration
NUTRITION ASSISTANCE DRUG TESTING AGREEMENT
A person who is convicted of a felony offense which has as an element of the offense “the use or possession of a con-
trolled substance”, may be eligible for Nutrition Assistance if the person agrees to random drug testing and meets at least
one of the following:
Is currently accepted in a substance abuse treatment program, but on a waiting list and remains enrolled in the
treatment program, and enters the treatment program at the first available opportunity.
Is currently accepted for treatment and is participating in a substance abuse treatment program.
Has successfully completed a substance abuse treatment program after the convicted offense.
Is determined by a licensed medical provider to not need substance abuse treatment.
When on probation for the felony drug conviction, is in compliance with the terms of probation.
Proof of the selected requirement must be provided. One of the requirements must be met after any disqualifying drug
conviction. Proof is needed no later than
.
Failure to sign this agreement and provide proof of one of the above requirements may cause your household’s Nutrition
Assistance benefits to decrease, stop or be denied.
IMPORTANT INFORMATION FOR YOU
SIGN AND DATE THIS FORM
I have read this form and agree to provide proof of the selected requirement, and agree to random drug testing.
Applicant’s Name (Please print)
Signature
Case Number
Date of Birth
Date
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Amer-
icans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975,
and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disabil-
ity, genetics and retaliation. To request this document in alternative format or for further information about this policy, con-
tact your local office manager; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon
request. Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
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