Form Faa-1097t - Young Adult Transitional Insurance (Yati) Tribal Referral
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3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page 1 of 3
FAA-1097T FORFF (9-17)
Family Assistance Administration
FAA DATE STAMP
YOUNG ADULT TRANSITIONAL INSURANCE (YATI)
TRIBAL REFERRAL
PID:
TO: FAA
TO:
FROM:
Social Services
Research and Analysis Unit
SOCIAL WORKER
DATE
Mail Drop 33S3
SOCIAL SERVICES
DATE
Phone No.: 602-774-5749
Fax No.: 602-257-7035
PHONE NUMBER
FAX NUMBER
PHONE NUMBER
FAX NUMBER
E-Mail:
FAAYATI@azdes.gov
INFORMATION ABOUT YATI CUSTOMER
NAME (Last, First, M.I.)
MAIDEN NAME, ALIAS, AND OTHER NAME(S) USED
DATE THE YOUTH LEFT FOSTER CARE:
If completing this form for a youth aging out of the system complete the rest of the form, sign and date.
INFORMATION ABOUT YATI CUSTOMER’S ADDRESS
(Refer to instructions if current address is unknown)
ADDRESS (No., Street) (If rural location, give directions)
CITY
STATE
ZIP CODE
PHONE NO.
MAILING ADDRESS (No., Street) (If different from above)
CITY
STATE
ZIP CODE
MESSAGE PHONE NO.
FAMILY MEMBERS THAT WILL BE LIVING WITH THE YATI CUST OMER
(Parents, spouse, siblings, and customer’s own children)
RELATIONSHIP TO
SEX
NAME (Start with Customer)
SOCIAL SECURITY NO.
DATE OF BIRTH
CUSTOMER
(M or F)
SELF
INFORMATION FOR ELIGIBILITY
A. Is the Customer pregnant?
Yes
No
If Yes, how many babies are expected?
What is the due date?
B. Is the Customer a U.S. citizen?
Yes
No
If No, is the Qualified Non-Citizen?
Yes
No
If Yes, what is the Qualified non-citizen status:
(see list of qualified non-citizen statuses on page 3)
C. Is the Customer working?
Yes
No
If Yes, enter the Customer’s work information below.
EMPLOYER’S NAME
PHONE NO.
HOURS PER WEEK
HOURL Y PAY
HOW OFTEN PAID
D. Does the Customer have any other income?
Child Support
Social Security/SSI
Other:
If Yes, how much is received?
How often is this income received?
E. Does the Customer expect to be claimed as a tax dependent for this tax year?
Yes
No
If Yes, who will claim the Customer as a tax dependent?
Is this person a parent, step-parent or spouse?
Yes
No
If No, does the Customer expect to file a tax return for this tax year?
Yes
No
See page 2 for USDA/EOE/ADA/LEP/GINA disclosures
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