Form Fa-001 - Application For Benefits (Page 4 of 31) in pdf

Do you need help with this application? Visit

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

Do I need a Social Security number?

Federal law requires you give a Social Security number (SSN) for anyone who wants to get AHCCCS

Medical Assistance, help with Medicare costs, Nutrition Assistance, Cash Assistance, and/or

Tuberculosis Control (42 U.S.C. § 1320b-7; 42 U.S.C. § 405(c)(2)(C), 7 U.S.C. §§ 2011-2036, and

Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369).

 If you or anyone you are applying for does not have a Social Security number, we will refer you to the

Social Security office to apply for one. Immigrants who are not legally able to get a Social Security

number are not required to give one or apply for one. Any person you are applying for who is legally

able to get a Social Security number but does not have one or does not apply for one will not be

eligible for benefits.

 If you are not applying for benefits for yourself, you do not have to give us your Social Security

number. However, it may reduce the total amount of Nutrition Assistance and/or Cash Assistance

benefits for the person you are applying for because we will not include you in the benefit amount.

 We will not use your SSN as your DES or AHCCCS identification number.

 We will not give any Social Security numbers to the United States Citizenship and Immigration

Services (USCIS).

We use your information, including Social Security number, to:

Verify identity

•

Verify citizenship and immigration status

•

Verify income and resources

•

Prevent duplicate benefits

•

Establish and enforce child support

•

Computer match with state, local and federal agencies and our other programs to verify information.

•

Information available through the Income and Eligibility Verification System (IEVS) will be requested,

used and may be verified through collateral contacts when discrepancies are found. This information

may affect eligibility and benefit level.

Collect money we overpaid you in the form of benefits

•

Share with other government agencies and their contractors to assess Nutrition Assistance and/or

•

Cash Assistance program management and compliance

We may give your information to law enforcement officials for the purpose of arresting persons fleeing

•

to avoid the law

If we are not able to find proof of the information you have given us through the sources available to us,

then you must provide proof of the information for us to decide if you are eligible.

DES and/or AHCCCS will keep your information for at least 7 years.

Do I have to give information about my citizenship and immigration status?

To get the most help, you need to give us information about citizenship and immigration status for each

person who is applying for help.

• Giving us the citizenship and immigration status for all people who are eligible for benefits allows us to

include them in the Nutrition Assistance and/or Cash Assistance benefit amount. When you do not

give us this information, it will not affect the eligibility of the people you are applying for who have given

us verification of their citizenship or qualified non-citizen status, but it may affect the amount of the

benefits for these people.

• If you choose not to give us information regarding immigration status but still want AHCCCS Medical

Assistance, you may only be eligible for emergency medical services.

• You do not need to give us information about citizenship and immigration status for any person who is

not applying.

• You do need to give us information on income, resources, or other information for those who have not

given us citizenship or immigration status information to complete the application process.

• Under federal law, certain non-citizens such as refugees or political asylees may qualify for Medical

Assistance, Nutrition Assistance, and/or Cash Assistance. For those non-citizens, United States

Citizenship and Immigration Services (USCIS) guidelines state that use of these benefits will not affect

your ability to become a Lawful Permanent Resident.

• If you are not applying for any benefits or if you choose not to provide citizenship or immigration

information, we will not try to find out this information from USCIS.

• We will not report you, a family, or a household member to U.S. Immigration and Customs Enforcement

(ICE) unless you inform us that you, your family or a household member is in the U.S. illegally.

• Households with different immigration statuses may apply for benefits on behalf of US Citizen children

and other eligible family members.

FA-001 (12-17)

Page D

Form Fa-001 - Application For Benefits Page 4

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