Form Faa-1584a - Puerto Rico Evacuee Affidavit
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-1584A FORENG (10-17)
Division of Benefits & Medical Eligibility
PUERTO RICO EVACUEE AFFIDAVIT
Affidavit for Supplemental Nutrition Assistance Program (SNAP) applicants who were receiving Nutrition
Assistance Program (NAP) when they were displaced from Puerto Rico due to Hurricanes Irma or Maria
INSTRUCTIONS
If you would like to apply for Supplemental Nutrition Assistance (SNAP) benefits and you were receiving Nutrition
Assistance Program (NAP) benefits in Puerto Rico, you must fill out the following information and attest that you will not
participate in both programs at the same time.
NAME (Head of household)
DATE OF BIRTH
NAME (Other members of households)
AZTECS CASE NUMBER (If available)
CURRENT ADDRESS IN ARIZONA
HOME ADDRESS IN PUERTO RICO
NAP CASE NUMBER (If available)
STATEMENT AGAINST DUPLICATE PARTICIPATION
I understand that each member of my household may not receive benefits from the Nutrition Assistance Program (NAP)
and the Supplemental Nutrition Assistance Program (SNAP) at the same time. If I am found eligible for SNAP benefits,
I attest under penalty of perjury and disqualification that I will not participate in both programs at the same time and will
close my household’s NAP case at the earliest possible opportunity.
SIGNATURE
DATE
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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