Form Faa-1097t - Young Adult Transitional Insurance (Yati) Tribal Referral Page 2
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3FAA-1097T FORFF (9-17)
Page 2 of 3
INFORMATION FOR ELIGIBILITY (continued)
F. If the Customer will be living with a parent, step-parent, spouse, siblings under 19, or their own child and any of them
have income, complete the information below:
HOW MUCH DOES THIS
NAME OF PERSON WITH INCOME
HOW OFTEN
INCOME SOURCE
PERSON GET
G. Customer’s AHCCCS Health Plan choice:
H. Does the Customer want to receive electronic alerts when eligibility decisions are made or more information is needed?
Email:
Yes
No
If Yes, email address:
Text:
Yes
No
If Yes, number to text (standard text rates apply):
ATTESTATION AND SIGNATURE
TRIBAL SOCIAL WORKER’S NAME (Please Print)
SIGNATURE
DATE
I.
Does the Customer want to designate an Authorized Representative(s) who can provide information on their behalf
to complete the application process?
Yes
No
If yes, Authorized Representative’s Name and contact number:
TRIBAL SOCIAL WORKER’S NAME (Please Print)
SIGNATURE
DATE
FAA DETERMINATION – COMPLETED BY FAA
EFFECTIVE DATE
DATE NOTICE SENT
Approved
MA Category:
Denied
Reason:
Stopped
Reason:
TAD SENT TO TRIBAL SOCIAL SERVICES:
Yes
No
COPY OF NOTICE ATTACHED:
Yes
No
ELIGIBILITY INTERVIEWER’S SIGNATURE
DATE
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA,
its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating
based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information
(e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied
for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a
program complaint of discrimination, complete the
USDA Program Discrimination Complaint
Form, (AD-3027) found online at:
, and at any USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed
form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights 1400 Independence
Avenue SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal
opportunity provider.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans 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, disability, genetics and retaliation. To request this document
in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language
assistance for DES services is available upon request.
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