Form Fa-001 - Application For Benefits (Page 26 of 31) in pdf

Do you need help with this application? Visit

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

Voter Registration:

Tell us if any person over the age of 18 listed on this application would like to register to vote.

If you are not registered to vote where you live now, would you like to apply to register to vote here today? Please go to the

last attached page of this application, which is the “Offer of Voter Registration” form. Read the information, check “Yes” or “No”,

and then sign and date the form where indicated.

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this

agency.

If you do not check either box, you will be considered to have decided not to register to vote at this time.

If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or

accept help is yours. You may fill out the application form in private.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in

deciding whether to register to vote, or your right to choose your own political party or other political preference, you may file a

complaint with the State Election Director, Secretary of State’s Office, 1700 West Washington, Phoenix, AZ 85007,

602-542-8683.

You may also get a voter registration form at

Submit the Application:

Submit your completed and signed application along with any supporting documents to the:

Arizona Department of Economic Security

Family Assistance Administration

P.O. Box 19009

Phoenix, Arizona 85005-9009

If any additional information is needed, you will be contacted.

You will be notified of our decision.

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some

cases religion or political beliefs.

The U.S Department of Agriculture also prohibits discrimination against its customers, employees, and applicants for

employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where

applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income

is derived from any public assistance program, or protected genetic information in employment or in any program or activity

conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination with USDA, complete the USDA Program

Discrimination Complaint Form, found online at , or at any USDA

office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the

form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of

Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at

program.intake@usda.gov.

FA-001 (12-17)

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Form Fa-001 - Application For Benefits Page 26