Form Fa-077-Pf - Information Request And Pending Information Agreement
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2FA-077-PF (10-12)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Family Assistance Administration
INFORMATION REQUEST AND PENDING INFORMATION AGREEMENT
CASE NAME
APPLICANT’S NAME (Last, First, M.I.)
AZTECS CASE NO.
LOCAL OFFICE ADDRESS (No., Street, City, State, ZIP)
(Check all that apply)
NA/CA/RCA/TC
MA
RETURN THIS FORM WITH THE VERIFICATION REQUESTED FOR ITEM(S) CHECKED ( ) BELOW
NEEDED FOR
NEEDED FOR
ITEMS
NA CASH MAO
PERSON(S) MONTH(S)
Proof of pregnancy – Estimated delivery date:
(For free pregnancy test, call 1-800-833-4642)
Identity
Residential address/Temporary residence status
Birth/Baptism certificate/Tribal Census card/Biodata Information/Age verification
Verification of citizenship, non-citizen status or 40 quarters
Social Security number/Application for Social Security number
Divorce decree/Child support orders/Marriage license
Verification of school attendance/Program completion date
Signed statement by landlord or non-relative verifying who lives in the home.
Landlord/non-relative must not be living in the same home.
(Must include address and phone number of person writing)
Separate food buying/Preparing statement
Doctor’s statement of disability including length of disability/emergency episode
Verification of all medical expenses incurred.
From
To
Cooperation with:
DCSE
Jobs Program Preliminary Orientation (JPPO)
Jobs Program
Native Employment Works (NEW)
Current statement for all bank/credit union accounts/IDA transactions
Real property (Lots, buildings, home, land, etc.)
Other personal property (Bonds, jewelry, life insurance, livestock, etc.)
Student income (Grants, scholarships, loans, work study, etc.)
Student expenses (Tuition, books, transportation, etc.)
Gross earned income (Pay stubs or employer’s signed statement) for each pay
period. Listed by pay period end, pay date and gross pay for each pay date
From
To
Self-employment income:
New
On-going
Time period: From
To
Self-employment expenses
Time period: From
To
Other income:
SSI
SSA
VA
UI
Child Support
In-Kind
Time period: From
To
Verification that income has stopped and date:
Last day paid
Last day worked
Mortgage
Rent
Rental space
Property tax
Homeowner’s Ins.
Utilities:
Electric
Water
Gas
Phone
Other (specify)
Statement of how expenses have been paid, amounts and who pays them
Dependent care expenses: Billed for
Time period: From
To
Application for other benefits (specify SSI, UI, VA, RR, etc.)
Type of benefit:
Fingerprint Imaging
Overpayment income and expenses.
Time period: From
To
Other (specify)
RETURN TO
SITE CODE
UNIT
AREA CODE AND PHONE NO.
EI’S SIGNATURE
DATE
Click to "Sign" with 10 days
Click to "Sign" with 20 days
STATEMENT OF UNDERSTANDING: The need for the proof of the item(s) checked above has been explained to me. I understand
my responsibility to provide this proof. I also understand that if I am unable to provide the proof, I will contact my EI for help. I will
provide proof by the following date:
. Failure to provide the requested proof may result in the benefit(s) marked above being
changed, denied, or stopped.
APPLICANT’S SIGNATURE
DATE
See reverse for EOE/ADA/LEP/GINA disclosures.
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