Form Faa-1570a - Cash Assistance Drug Conviction Sanction Agreement
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-1570A FORFF (8-17)
Family Assistance Administration
CASH ASSISTANCE DRUG CONVICTION SANCTION AGREEMENT
END FOR CA DRUG CONVICTION SANCTION
The person who is convicted August 9, 2017 or later, agrees to random drug testing and meets at least one of the
following criteria:
1. Successfully completes, or is accepted into, a substance abuse treatment program.
The person also meets this criteria if they are:
a. Currently accepted for treatment in a substance abuse treatment program, but is on a waiting list.
The person remains enrolled in the treatment program and enters the treatment program at the first
available opportunity.
b. Currently accepted for treatment, and is participating in a substance abuse treatment program.
2. Is determined by a licensed medical provider to not need substance abuse treatment.
3. If applicable, is in compliance with all terms of probation related to the conviction they were sanctioned for.
The person convicted of the felony drug conviction will be permanently disqualified. Once the minimum sanction
period has been imposed, the benefits will be returned to the total eligible benefit amount for the remaining
household members.
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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