Form Fa-001 - Application For Benefits Page 16
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31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Select one or more answers for each person applying for benefits is voluntary and will not effect
Race/Ethnicity:
eligibility or benefit level. This information is to assure that program benefits are distributed without regard to race,
color, or national origin.
Race
If Hispanic/Latino, check ethnicity:
Person
Main
Contact
Person 2
Person 3
Person 4
Person 5
Person 6
Complete this section if anyone applying is an American Indian
American Indian and Alaskan Native Persons:
or Alaska Native.
Received services from
Enrolled in
Indian Health Service;
Federally
Recognized
Name of
a tribal health program;
If no, is the person
Person
Tribe
Tribe
eligible to receive
urban health program; or
services?
through a referral from one of
these programs?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Living on a
Person
Name of Reservation
Tribal Census Number
Reservation?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
FA-001 (12-17)
Page
7
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