Form Faa-1097a - Young Adult Transitional Insurance (Yati) Referral Page 2
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3FAA-1097A 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?
FAA DETERMINATION – COMPLETED BY FAA
Email:
Yes
No
If Yes, email address:
Text:
Yes
No
If Yes, number to text (standard text rates apply):
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:
DCS SPECIALIST’S NAME (Please Print)
DCS SPECIALIST’S SIGNATURE
DATE
EFFECTIVE DATE
DATE NOTICE SENT
Approved
MA Category:
Denied
Reason:
Stopped
Reason:
TAD SENT TO DCS:
Yes
No
COPY OF NOTICE ATTACHED:
Yes
No
ELIGIBILITY INTERVIEWER’S SIGNATURE
DATE
IUSDA is an equal opportunity provider and employer.
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on
the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and, where applicable, political beliefs, marital
status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program,
or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited
bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found
online at , or at any USDA office, or call (866) 632-9992 to request the form. You may
also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at
U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax
(202) 690-7442 or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint please contact
USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish). Persons with Disabilities, who wish to file a
program complaint, please see information above on how to contact us by mail directly or by email. If you require alternative means of
communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-
2600 (voice and TDD).
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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