Form Faa-1544a - Indigent Exception Worksheet
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-1544A FORFF (9-17)
Family Assistance Administration
INDIGENT EXCEPTION WORKSHEET
CUSTOMER’S NAME (Last, First, M.I.)
NUMBER
Family Size (Count the following individuals who live in the customer’s household: the customer, the customer’s spouse,
dependent children of the customer or the customer’s spouse).
Total Family size =
Cash provided by sponsor
$
+
Value of vendor payments for the customer’s food and/or shelter
$
+
Customer’s other gross income (earned and unearned)
$
+
Customer’s spouse’s gross income
$
=
Total
$
130% of FPL for customer’s family size
$
If the total is...
Then...
•
Greater than 130% of the FPL
The customer is not indigent. Deem the sponsor’s income to
the customer.
•
Equal to or less than 130% of the FPL
The customer is indigent and qualifies for the Indigent Exception.
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.
• Disponible en español en línea o en la oficina local.
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