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Get AZ FA-100 2009

Ing ONLY if you want a Fair Hearing 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 Employment Program AHCCCS Health Insurance Tuberculosis Control I Want a Fair Hearing because I do not agree with: (Check Box) Closure Amount of Benefits DATE OF NOTICE I DO NOT AGREE WITH Denial Overpayment Other (Explai.

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