Form Fa-001 - Application For Benefits Page 20
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Answer the following questions for everyone who is applying for benefits.
Questions for All Applicants:
If Yes, who?_______________________________
Is any adult you are applying for not able to work because of a
medical or mental condition that has lasted or may last
Yes No
Date of last day worked?_____________________
12 months, or might result in death?
Expected return date:________________________
Does any child you are applying for have a physical or
If Yes, who? ______________________________
mental condition that is disabling and has lasted or may last 12
Yes No
When did the condition begin? ________________
months, or result in death?
Is anyone you are applying for under age 65, have a disability
If Yes, who? _______________________________
Yes No
expected to last at least 12 months and is working?
Does anyone you are applying for need help with activities of
If Yes, who? _______________________________
daily living (bathing, dressing, etc.) through personal
Yes
No
assistance, services, nursing home, or other medical facility?
If Yes, who? _______________________________
Does anyone you are applying for have a legal guardian?
Yes
No
Name of legal guardian:______________________
Answer these questions for anyone who is applying for
Nutrition Assistance and Cash Assistance:
Nutrition Assistance and/or Cash Assistance.
Is anyone you are applying for a migrant or seasonal farm
Yes
No
If Yes, farm worker type:__________________
worker?
Is this person under contract/agreement to begin
Yes
No
employment within 30 days?
Yes
No
______________________
Is this person working a minimum of 30 hours a week?
If Yes, who?
Yes No
Are you or anyone you are applying for on strike?
If Yes, who?___________________________
Yes No
Are you or anyone you are applying for a boarder?
If Yes, who?___________________________
Did anyone get Nutrition Assistance benefits from any
If Yes, who received?_______________________
Yes
No
other state?
When?___________ State: _____________
Answer these questions if the MAIN CONTACT is
Nutrition Assistance and Cash Assistance Questions:
applying for Nutrition Assistance and/or Cash Assistance. Everyone may still be able to get benefits if he/she has a felony
drug conviction. See page G & H for more information.
Has anyone you are applying for been determined to be blind
If Yes, who? _________________________
or have a disability by:
Yes No
the Social Security Administration (SSA), or
the Veterans Administration (VA)?
Has anyone you are applying for had a felony conviction for
City/state of conviction: _________________
Yes No
possession, use, or distribution of a controlled substance on or
Date of conviction: _____________________
after August 23, 1996?
Type of conviction:_____________________
If you have a felony drug conviction and would like to get
Nutrition Assistance and/or Cash Assistance, do you
Yes No
agree to random drug testing?
__
Is anyone you are applying for:
___
•
Running from the law on any felony charges, or
If Yes, who? _________________________
Yes No
•
In violation of probation or parole?
Has anyone been found to have committed a Nutrition
If Yes, who? _________________________
Yes No
Assistance and/or Cash Assistance Intentional Program
Violation in Arizona or any other state?
What state?__________________________
FA-001 (12-17)
Page 11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal