Form Fa-001 - Application For Benefits (Page 11 of 31) in pdf

Do you need help with this application? Visit

or call 1-855-HEA-PLUS (432-7587).

Release of Information to Hospitals/Hospital Agents/Organizations/Agencies:

You may give permission to DES and AHCCCS to release information about applicant eligibility. AHCCCS and DES cannot share any

information about applicants without the applicant’s written permission. This section is OPTIONAL.

Name of Hospital/Hospital’s Agent/Organization/Agency: __________________________________________________________________

Contact Person: __________________________________________________________ Phone Number: __________________________

Mailing Address: _______________________________ City: ______________________ State: _____________ Zip Code: ____________

I give permission for DES and/or AHCCCS staff to tell the hospital, hospital agent, organization, or agency listed above:



That I have applied for help with insurance costs;



The information or proof needed to see if I can get help with insurance costs; and



If approved for help with insurance costs, the effective date of my eligibility, the redetermination due date, and the category of assistance for which

I was approved. If denied for help with insurance costs, the reason I was denied.

Signature of Applicant: ___________________________________________________________ Date: ____________________________

Access to Electronic Benefit Transfer (EBT) Account:

This section is OPTIONAL. If you are applying for Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control,

you may choose a person, called an Alternate Cardholder, to get your benefits for you. If you need an Alternate

Cardholder, choose a person you trust. Remember, lost or stolen benefits will not be replaced.

EBT Representative’s Name: _____________________________________________ EBT Representative’s Date of Birth: _____________

EBT Representative’s Mailing Address: ________________________________ City: _________________ State: ___ Zip Code: ________

EBT Representative’s Phone Number: ____________________________  Home  Cell  Work  Message  Other: __________

EBT Representative’s Other Phone Number: _______________________  Home  Cell  Work  Message  Other: __________

Signature of Applicant: _____________________________________________________ Date: __________________________________

Someone Who Knows You Well:

We often need to contact people or organizations that can verify information to determine your eligibility for public

assistance. When we contact these people or organizations we tell them your name, our title and that we work for the

Department of Economic Security (DES). We are prohibited by law from telling them anything about you or about your

assistance case. Please provide contact information below.

Name of someone who knows you well: ________________________________________Relationship to you:

__________________________

Mailing Address: _________________________________________________ City: ________________ State: _____ Zip Code: _________

Daytime Phone Number: ___________________________________________________________________________________________

Name of Landlord: __________________________Are you related to the Landlord?  Yes  No

If yes,

how?_______________________

Mailing Address: _________________________________________________ City: ________________ State: _____ Zip Code: _________

Daytime Phone Number: _________________________________________________________________________________________

Emergency Nutrition Assistance:

Is anyone in your household applying for Emergency Nutrition Assistance? If YES: fill out this section. If NO: go to page 3.

What is the total amount of income, before deductions, you expect to get this month?

What is the total amount of cash on hand and money in your checking and savings account?

What are the total monthly housing costs (rent or mortgage, taxes, homeowner/rental insurance, etc.)?

What are the total monthly utility costs (gas, electric, water, etc.)?

What is your monthly telephone cost?

Does anyone receive Tribal Food Distribution?

 Yes

 No

Is anyone a migrant or seasonal farm worker?

 Yes

 No

FA-001 (12-17)

Page

Form Fa-001 - Application For Benefits Page 11

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