Form Fa-001 - Application For Benefits Page 15
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31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Deceased Applicant:
Date Deceased
Who?
Is anyone you are applying for Deceased?
Yes
No
Prior Medical Expenses:
Who?
Month(s)?
Does anyone applying for benefits also need help with medical bills
Yes
No
in any of the last three months?
Yes
No
Does anyone in this application have Medicare and want help paying
their Medicare Part B premium for any of the last three months?
Tell us about any people who are temporarily living outside of your home who are expected to return.
Temporary Absence:
Expected
Why are they
Name (First and Last)
Date Left
Temporary Address
Return Date
out of the home?
Tell us about residency. You may need to provide proof of residency.
Residency for All Applicants:
Is each person applying for benefits a resident of Arizona?
Yes No
If No, who is not? __________________________________
Did any of the persons applying for benefits move to
Yes No
If Yes, who? ______________________________________
Arizona within the last four months?
Date moved: _______________
Answer the following questions for anyone who is applying for benefits.
Questions for All Applicants:
Is anyone applying for benefits currently in jail, prison or
Yes No
If Yes, who? ______________________________________
detention center?
Is this person currently serving a sentence based on being
convicted of a crime?
Yes No
Expected release date: ___________________
If Yes, who? ______________________________________
Has anyone applying for benefits been released from a
Yes No
jail, prison or detention center within the last four months?
Release date: _________________
FA-001 (12-17)
Page
6
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