Form Fa-001 - Application For Benefits Page 21
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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:
Yes
No
Is anyone on this application attending school?
If Yes, complete grid below:
Who
Name of School
Address
Full/Part
Grade
Start Date
Graduation date
Time
Level
Answer the following questions if anyone in your household is applying for Nutrition Assistance and/or
Expenses:
Cash Assistance.
Are you living in HUD housing?
Yes
No
Amount $_____________________
Rent $_____________ , Mortgage $________________ , Taxes $_______________
What are your monthly housing costs for?
Homeowner/rental insurance $_______________, Other $______________________
What are the total monthly utility costs for?
Gas $_________, Electric $____________, Water $___________, Other $___________
Are the persons you are applying for living in
Yes
No
government-assisted housing?
Yes
No
Are the persons you are applying for
homeless?
Answer the following questions about receiving benefits from other states and
Other Benefits and Expenses:
expenses for anyone disabled or is 60 or older.
If Yes, who? ________________________________
Has anyone on the application received Nutrition Assistance
Yes No
What type of benefits? ________________________
from another state?
When did benefits stop? ______________________
Name of state/country? _______________________
Has anyone on the application received Cash Assistance benefits
If Yes, who? _____________________________
Yes No
from another state?
When did the benefits stop? _________________
Name of state/country? _______________________
Is anyone on the application living in an assisted living facility
If Yes, who? ________________________________
Yes No
?
or group home
Yes No
Is anyone disabled or 60 or older?
If Yes, who?_________________________________
Does he/she have any paid or unpaid medical expenses,
Average Total Monthly Medical Expenses
even if he/she has medical insurance?
Yes No
(example: travel expenses to and from medical provider, doctor
$____________________________________
visits, prescriptions, lab work, etc.)
Answer these questions for everyone applying for Cash Assistance
Cash Assistance Questions:
Cash Assistance benefits are limited to 12 months unless the child is a ward of the State, is in the legal custody of a tribal court or a tribal
child welfare agency located in Arizona, or there is a hardship. An additional 12 months of cash assistance may be received when no adult
has been sanctioned for noncompliance with a Jobs Program requirement and all children in the household who are required to attend
school have a school attendance record of at least 90%, unless the child was excused.
Are you requesting an additional 12 months of Cash Assistance?
Yes
No
Has any adult in the household ever been sanctioned for Jobs
Yes
No
Program noncompliance?
Do
all
children
in
the
household
who
are
ages
6-15
Yes
No
have a school
attendance
record
of
at
least
90%, unless
the child was excused pursuant to A.R.S. §15-802?
If Yes, who? _____________________________
Has anyone you are applying for received Cash Assistance this month?
Yes
No
When did benefits stop? ____________________
Name of city/state: _________________________
What type of benefits?_______________________
Do all children under age 19 have current immunizations (shots)?
Yes
No
If no, who does not?______________________
Page 12
FA-001 (10-17)
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