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Get Fair Hearing Request For Arizona Form

FA-100-PD 8-14 ARIZONA DEPARTMENT OF ECONOMIC SECURITY Family Assistance Administration FAIR HEARING REQUEST Local Office Use Only Complete the following ONLY if you want a Fair Hearing Case Name Case No. Site Code Date Received Customer Information NAME Last First CASE NO. ADDRESS No. Street City State ZIP PHONE NO. Include area code I Want a Fair Hearing for the following program s Check Box Cash Assistance Nutrition Assistance Two-Parent Emplo.

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