Form Dd-525 - Application For Eligibility Determination
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5ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DD-525 FORPDF (9-17)
Division of Developmental Disabilities
ASSISTS I.D.
APPLICATION FOR ELIGIBILITY DETERMINATION
NEW ELIGIBILITY
REDETERMINATION OF ELIGIBILITY
APPLICANT’S INFORMATION
NAME (Last, First, M.I.)
DATE OF BIRTH
SEX
Male
Female
PHYSICAL ADDRESS
(No., Street, City, State, ZIP Code)
MAILING ADDRESS:
IF DIFFERENT FROM ABOVE (No., Street, State, ZIP Code)
COUNTY:
PHONE NO.
EMAIL ADDRESS:
MARITAL STATUS
LANGUAGE SPOKEN BY APPLICANT
RACE / ETHNICITY
American Indian / Alaska Native (Tribe)
Single
English
Married
Spanish
Asian / Pacific Islander
Separated
Black or African American (Not Hispanic)
Other
(Specify)
Divorced
Hispanic or Latino
Widowed
Other:
N/A
White Not Hispanic
ARE YOU A U.S. CITIZEN OR A PERMANENT RESIDENT ALIEN?
YES
NO
PLACE OF BIRTH (CITY, STATE, & COUNTRY)
TOTAL NUMBER IN HOUSEHOLD
APPLICANT’S MONTHLY INCOME
HAVE YOU EVER APPLIED FOR DDD SERVICES IN THE PAST? (If yes, please specify)
YES
NO
WHEN:
WHERE:
IF YOU ARE AT LEAST 18 YEARS OF AGE NOW, OR WILL BECOME 18 WITHIN THE NEXT 12 MONTHS, WOULD
YOU LIKE TO REGISTER TO VOTE?
YES
NO
N/A
PARENTS
NAME (Last, First, M.I.)
SOCIAL SECURITY NUMBER
(Voluntary)
MAILING ADDRESS
PHONE NUMBER
(NO. STREET, CITY, STATE, ZIP CODE)
SAME AS APPLICANT
EMPLOYER’S ADDRESS
PHONE NUMBER
(NO. STREET, CITY, STATE, ZIP CODE)
NAME (Last, First, M.I.)
SOCIAL SECURITY NUMBER
(Voluntary)
MAILING ADDRESS
PHONE NUMBER
(NO. STREET, CITY, STATE, ZIP CODE)
SAME AS APPLICANT
EMPLOYER’S ADDRESS
PHONE NUMBER
(NO. STREET, CITY, STATE, ZIP CODE)
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