Form Faa-1493a Forpf - Nutrition Assistance Authorized Representative Request
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2FAA-1493A FORPF (10-13)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Family Assistance Administration
NUTRITION ASSISTANCE
AUTHORIZED REPRESENTATIVE REQUEST
CASE NAME (Last, First, M.I)
CASE NO.
DATE
You may choose an Authorized Representative to help you with the requirements of applying for or getting
benefits. An Authorized Representative is a friend, relative or other person who has a concern for your well-
being. An Authorized Representative is a person you choose. We will not choose one for you. The person you
choose must agree to help you. An agency cannot act as an authorized representative, but an individual at an
agency can. An Authorized Representative must be a person that does not live with you. An Authorized
Representative may go to interviews for you. They may fill out an application form and other paperwork for you.
They may also report changes in your income, resources or other changes for you.
AUTHORIZED REPRESENTATIVE
I want the person identified below as my Authorized Representative. I understand that this person will be
able to:
• Complete my application, forms and other Department paperwork for me.
• Attend eligibility interviews and conduct telephone eligibility interviews for me.
• Provide my proof of income, resources and other case information, and report and verify changes in my
case circumstances for me.
• Receive my notices and other mail from the Department for me.
AUTHORIZED REPRESENTATIVE INFORMATION
PERSON’S NAME (Last, First, M.I)
PERSON’S PHONE NUMBER (Include area code)
PERSON’S MAILING ADDRESS (No., Street, City, State, ZIP Code)
THIS PERSON IS KNOWN TO ME AS (Your relationship to this person)
THE REASON I OR MY SPOUSE CANNOT BE INTERVIEWED IS
Continue to page 2 – Both you and your authorized representative must sign this form.
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