Form Faa-1415a Forna - Illegal Drug Use Statement printable pdf download

FAA-1415A FORNA (2-10)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Family Assistance Administration

ILLEGAL DRUG USE STATEMENT

Effective November 24, 2009, state law prevents DES from giving Cash Assistance to any person age 18 or older who

tests positive for the illegal use of a controlled substance. Illegal use of a controlled substance (illegal drug) means:

•

The use of a drug that is against the law, or

•

The use of a prescription drug which is an illegal drug, that is not prescribed for you.

When DES has reasonable cause to believe that a person uses illegal drugs, that person must complete a drug test.

Each person age 18 or older in your Cash Assistance case must answer the following questions and return this

form to DES no later than _________________________.

ANSWER EACH OF THE FOLLOWING QUESTIONS

Yes

In the past 30 days have you used any illegal drugs?

Yes

In the past 30 days have you lost or been denied a job due to current illegal drug use?

Yes

In the past 30 days have you recently had legal trouble due to current illegal drug use?

IMPORTANT INFORMATION FOR YOU

If you do not fill out this form and return it to DES by the date above, you will be removed from the Cash

Assistance payment until the completed statement is given to us. We will send you a separate notice if we take this

action. Cash Assistance will be issued only for the eligible household members. You will continue to get Cash

Assistance payments for the eligible members of your household.

•

While getting Cash Assistance, adult household members may have to complete a drug test if DES has reasonable

cause to believe they are using illegal drugs.

•

If you test positive for illegal drugs you will not be able to get Cash Assistance benefits for 12 months. You will

continue to get Cash Assistance benefits for the eligible members of your household.

SIGN AND DATE THIS FORM

I have read this form and answered each question truthfully. I understand that I will have to complete a drug test if DES

has reasonable cause to believe that I am using illegal drugs. I understand that if I test positive for the use of illegal drugs,

I will not get Cash Assistance for 12 months.

_______________________________________________

____________________________________________

Applicant’s Name (Please print)

Signature

____________________________________________

Date

DES/TANF/USDA are Equal Opportunity Providers/Employers • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI &

VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age

Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment

based on race, color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to

allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department

must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also

means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity,

including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or

activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in

alternative format or for further information about this policy, contact your local office manager; TTY/TDD Services: 7-1-1. •

Disponible en español.

Form Faa-1415a Forna - Illegal Drug Use Statement

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