Get Az Fa-100 2018-2025

The AZ FA-100 form is essential for individuals seeking to appeal decisions made by the Arizona Department of Economic Security regarding assistance programs. This guide provides step-by-step instructions on how to complete the form online, ensuring a smooth and efficient filing process.

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

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the customer information section. Enter the case name, case number, and mailing drop information as needed. Provide your full name (last, first, middle initial) and social security number. Then, enter your address, including street number, city, state, and ZIP code. Include a contact phone number with the area code.
3. In the section titled 'I want an appeal for the following programs', check the appropriate boxes for which programs you are appealing. Options include cash assistance, nutrition assistance, AHCCCS health insurance, and tuberculosis control.
4. Next, specify the reason for your appeal in the section 'I want an appeal because I do not agree with'. Check one or more boxes that apply, such as the end of benefits, amount of benefits, denial of application, or overpayment. If you select 'Other', be sure to provide an explanation.
5. In the 'Reason(s) Why I don’t agree with your decision' field, clearly explain your reasoning. Include the date of the notice you disagree with.
6. If applicable, indicate whether you need an interpreter for the appeal process. If yes, mention what language is needed. Similarly, specify if you require accommodation for a disability.
7. For the continued benefits section, choose whether you want to keep receiving benefits during your appeal or not by checking the appropriate box. Note that benefits may continue automatically if no option is selected.
8. Print or type your name in the signature section, sign the form, and enter the current date.
9. Review all entered information for accuracy and completeness. After confirming everything is correct, you can proceed to save your changes, download, print, or share the form as needed.

Complete your AZ FA-100 form online today to ensure your appeal is submitted promptly.