Form Faa-1097a - Young Adult Transitional Insurance (Yati) Referral
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3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-1097A FORFF (9-17)
Page 1 of 3
Family Assistance Administration
FAA DATE STAMP
YOUNG ADULT TRANSITIONAL INSURANCE (YATI)
REFERRAL
PID:
TO: FAA
TO:DCS
FROM:
Department of Child Safety (DCS)
Research and Analysis Unit
DCS SPECIALIST
DATE
Mail Drop 33S3
DCS SPECIALIST
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
MAIDEN NAME, ALIAS, AND OTHER NAME(S) USED
(Last, First, M.I.)
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
CITY
STATE
PHONE NUMBER
(No., Street) (If rural location, give directions)
MAILING ADDRESS
CITY
STATE
MESSAGE PHONE N.O
(No., Street) (If different from above)
FAMILY MEMBERS THAT WILL BE LIVING WITH THE YATI CUSTOMER
(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
HOURLY 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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