Get Fa-100 - Fair Hearing Request - Arizona Department Of Economic ...

Filling out the FA-100 Fair Hearing Request form is an important step for individuals seeking a fair hearing regarding decisions made by the Arizona Department of Economic Security. This guide provides clear, step-by-step instructions to help users complete the form efficiently and effectively online.

Follow the steps to successfully complete the FA-100 form online.

1. Click the ‘Get Form’ button to access the FA-100 Fair Hearing Request form and open it in the editor.
2. Fill in your personal information in the 'Customer Information' section, including your name, social security number, case number, address, and phone number. Ensure all details are accurate for proper identification.
3. Select the program(s) for which you are requesting a fair hearing by checking the appropriate box(es). Options include Cash Assistance, Nutrition Assistance, AHCCCS Health Insurance, and Tuberculosis Control.
4. Indicate the reason for your request by checking the relevant box(es) under 'I Want a Fair Hearing because I do not agree with...'. Provide an explanation if you select 'Other' by detailing your situation.
5. Specify the date of the notice you disagree with, and if you need an interpreter or require an accommodation for a disability, check 'Yes' or 'No' and provide necessary details.
6. Indicate whether you wish to continue receiving benefits during the Fair Hearing by checking one of the provided boxes.
7. Print or type your name in the designated area, sign the form, and include the date of signing.
8. After completing the form, review all entered information for accuracy. Save your changes, download, print, or share the form according to your preference.

Submit your FA-100 Fair Hearing Request online today to ensure your voice is heard.