Form FAA-1097T FORFF "Young Adult Transitional Insurance (Yati) Tribal Referral" - Arizona

What Is Form FAA-1097T FORFF?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FAA-1097T FORFF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form FAA-1097T FORFF "Young Adult Transitional Insurance (Yati) Tribal Referral" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page 1 of 3
FAA-1097T FORFF (9-17)
Family Assistance Administration
FAA DATE STAMP
YOUNG ADULT TRANSITIONAL INSURANCE (YATI)
TRIBAL REFERRAL
PID:
TO: FAA
TO:
FROM:
Social Services
Research and Analysis Unit
SOCIAL WORKER
DATE
Mail Drop 33S3
SOCIAL SERVICES
DATE
Phone No.: 602-774-5749
Fax No.: 602-257-7035
PHONE NUMBER
FAX NUMBER
PHONE NUMBER
FAX NUMBER
E-Mail:
FAAYATI@azdes.gov
INFORMATION ABOUT YATI CUSTOMER
NAME (Last, First, M.I.)
MAIDEN NAME, ALIAS, AND OTHER NAME(S) USED
DATE THE YOUTH LEFT FOSTER CARE:
If completing this form for a youth aging out of the system complete the rest of the form, sign and date.
INFORMATION ABOUT YATI CUSTOMER’S ADDRESS
(Refer to instructions if current address is unknown)
ADDRESS (No., Street) (If rural location, give directions)
CITY
STATE
ZIP CODE
PHONE NO.
MAILING ADDRESS (No., Street) (If different from above)
CITY
STATE
ZIP CODE
MESSAGE PHONE NO.
FAMILY MEMBERS THAT WILL BE LIVING WITH THE YATI CUST OMER
(Parents, spouse, siblings, and customer’s own children)
RELATIONSHIP TO
SEX
NAME (Start with Customer)
SOCIAL SECURITY NO.
DATE OF BIRTH
CUSTOMER
(M or F)
SELF
INFORMATION FOR ELIGIBILITY
A. Is the Customer pregnant?
Yes
No
If Yes, how many babies are expected?
What is the due date?
B. Is the Customer a U.S. citizen?
Yes
No
If   No,   is   the   Qualified   Non-Citizen?  
Yes
No
If   Yes,   what   is   the   Qualified   non-citizen   status: 
(see list of qualified non-citizen statuses on page 3)
C. Is the Customer working?
Yes
No
If Yes, enter the Customer’s work information below.
EMPLOYER’S NAME
PHONE NO.
HOURS PER WEEK
HOURL Y PAY
HOW OFTEN PAID
D. Does the Customer have any other income?
Child Support
Social Security/SSI
Other:
If Yes, how much is received?
How often is this income received?
E. Does the Customer expect to be claimed as a tax dependent for this tax year?
Yes
No
If Yes, who will claim the Customer as a tax dependent?
Is this person a parent, step-parent or spouse?
Yes
No
If   No,   does   the   Customer   expect   to   file   a   tax   return   for   this   tax   year?  
Yes
No
See page 2 for USDA/EOE/ADA/LEP/GINA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page 1 of 3
FAA-1097T FORFF (9-17)
Family Assistance Administration
FAA DATE STAMP
YOUNG ADULT TRANSITIONAL INSURANCE (YATI)
TRIBAL REFERRAL
PID:
TO: FAA
TO:
FROM:
Social Services
Research and Analysis Unit
SOCIAL WORKER
DATE
Mail Drop 33S3
SOCIAL SERVICES
DATE
Phone No.: 602-774-5749
Fax No.: 602-257-7035
PHONE NUMBER
FAX NUMBER
PHONE NUMBER
FAX NUMBER
E-Mail:
FAAYATI@azdes.gov
INFORMATION ABOUT YATI CUSTOMER
NAME (Last, First, M.I.)
MAIDEN NAME, ALIAS, AND OTHER NAME(S) USED
DATE THE YOUTH LEFT FOSTER CARE:
If completing this form for a youth aging out of the system complete the rest of the form, sign and date.
INFORMATION ABOUT YATI CUSTOMER’S ADDRESS
(Refer to instructions if current address is unknown)
ADDRESS (No., Street) (If rural location, give directions)
CITY
STATE
ZIP CODE
PHONE NO.
MAILING ADDRESS (No., Street) (If different from above)
CITY
STATE
ZIP CODE
MESSAGE PHONE NO.
FAMILY MEMBERS THAT WILL BE LIVING WITH THE YATI CUST OMER
(Parents, spouse, siblings, and customer’s own children)
RELATIONSHIP TO
SEX
NAME (Start with Customer)
SOCIAL SECURITY NO.
DATE OF BIRTH
CUSTOMER
(M or F)
SELF
INFORMATION FOR ELIGIBILITY
A. Is the Customer pregnant?
Yes
No
If Yes, how many babies are expected?
What is the due date?
B. Is the Customer a U.S. citizen?
Yes
No
If   No,   is   the   Qualified   Non-Citizen?  
Yes
No
If   Yes,   what   is   the   Qualified   non-citizen   status: 
(see list of qualified non-citizen statuses on page 3)
C. Is the Customer working?
Yes
No
If Yes, enter the Customer’s work information below.
EMPLOYER’S NAME
PHONE NO.
HOURS PER WEEK
HOURL Y PAY
HOW OFTEN PAID
D. Does the Customer have any other income?
Child Support
Social Security/SSI
Other:
If Yes, how much is received?
How often is this income received?
E. Does the Customer expect to be claimed as a tax dependent for this tax year?
Yes
No
If Yes, who will claim the Customer as a tax dependent?
Is this person a parent, step-parent or spouse?
Yes
No
If   No,   does   the   Customer   expect   to   file   a   tax   return   for   this   tax   year?  
Yes
No
See page 2 for USDA/EOE/ADA/LEP/GINA disclosures
     
   
   
   
   
   
   
   
   
   
   
   
   
   
   
FAA-1097T FORFF (9-17)
Page 2 of 3
INFORMATION FOR ELIGIBILITY (continued)
F. If the Customer will be living with a parent, step-parent, spouse, siblings under 19, or their own child and any of them
have income, complete the information below:
HOW MUCH DOES THIS
NAME OF PERSON WITH INCOME
HOW OFTEN
INCOME SOURCE
PERSON GET
G. Customer’s AHCCCS Health Plan choice:
H. Does the Customer want to receive electronic alerts when eligibility decisions are made or more information is needed?
Email:
Yes
No
If Yes, email address:
Text:
Yes
No
If Yes, number to text (standard text rates apply):
ATTESTATION AND SIGNATURE
TRIBAL SOCIAL WORKER’S NAME (Please Print)
SIGNATURE
DATE
I.
Does the Customer want to designate an Authorized Representative(s) who can provide information on their behalf
to complete the application process?
Yes
No
If yes, Authorized Representative’s Name and contact number:
TRIBAL SOCIAL WORKER’S NAME (Please Print)
SIGNATURE
DATE
FAA DETERMINATION – COMPLETED BY FAA
EFFECTIVE DATE
DATE NOTICE SENT
Approved
MA Category:
Denied
Reason:
Stopped
Reason:
TAD SENT TO TRIBAL SOCIAL SERVICES:
Yes
No
COPY OF NOTICE ATTACHED:
Yes
No
ELIGIBILITY INTERVIEWER’S SIGNATURE
DATE
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA,
its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating
based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information
(e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied
for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a
program complaint of discrimination, complete the
USDA Program Discrimination Complaint
Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed
form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights 1400 Independence
Avenue SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal
opportunity provider.
Equal Opportunity Employer/Program • 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, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document
in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language
assistance for DES services is available upon request.
   
   
   
   
   
   
   
   
   
  
  
   
   
   
   
   
   
   
   
Completion Instructions for the FAA-1097T
FAA-1097T FORFF (9-17)
Page 3 of 3
YOUNG ADULT TRANSITIONAL (YATI) TRIBAL REFERRAL
I.
Purpose. This form is used to send updated information to DBME/FAA on children aging out of foster care for an eligibility
redetermination. It is also used to communicate the results of the determination to Tribal Social Services.
II.
Completion. Complete all items as follows (items not listed are self-explanatory):
FROM
Social Services: Tribal Social Services staff enters the Tribe name in the “From field, then enters his or her
name, phone and fax numbers and the date the form is sent to FAA.
TO FAA: The Tribal Social Services staff checks the box.
TO
Social Services: The FAA Eligibility Interviewer checks the box and enters the Tribe name, the Tribal Social
Services staff member’s name, phone and fax numbers and the date the form is routed to FAA.
INFORMATION ABOUT YATI CUSTOMER
Customer’s Name: Enter YATI Customer’s last name, first name and middle name.
WHERE WILL THE CUSTOMER BE LIVING?
Address: Enter the Customer’s anticipated residential address once he or she ages out of foster care. Include mailing address
if different) and any telephone contact numbers. If the anticipated address is not known, enter the last known address if there is a
reasonable expectation that the Customer will reside at that address, and note as “LKA”. If there is no anticipated residential address
or LKA appropriate for use and the DCS Specialist has reason to believe the Customer is residing in the state, enter the following
general delivery address:
FAMILY MEMBERS THAT WILL BE LIVING WITH THE CUSTOMER:
Enter name, Social Security number, sex, and date of birth of the Customer on the first row. Then list the same information for any
of the following family members with whom the Customer will be living after aging out of foster care:
Parent, step-parent, spouse, sibling, and Customer’s own child(ren). If a family member’s Social Security Number or exact date
of birth is not available, enter “unknown”.
INFORMATION FOR ELIGIBILITY:
Item A: Enter pregnancy information (proof of pregnancy is not required).
Item B: Enter U.S. Citizenship/Qualified Non-citizen status information. Qualified Non-citizen statuses are:
Cuban-Haitian Entrant
Afghan and Iraqi Special Immigrant Visa
Hmong or Laotian Highlander
Deportation withheld or removal withheld
Lawful Permanent Resident (LPR)
Amerasian Refugee
Parolee for at least one year
Asylee
Refugee
Battered Non-citizen
Victim of trafficking
Conditional Entrant
Item C through F: Enter the information for each applicable factor, and attach copies of any available proof. If the proof is not
available   from   the   Customer’s   file   or   through   a   collateral   contact,   do   not   delay   submitting   the   form   to   collect   proof.   Some   proof   may  
be available electronically through HEAplus’ data hubs. If more proof is needed, the eligibility worker will contact you.
Item G: Enter the Customer’s choice of AHCC CS health plan. If not ready to make a choice, enter “no choice made”.
Item H: Explain electronic notifications and enter Customer’s decision, and if applicable, the email or phone number. The Tribal
Social Services staff member prints and signs his/her name.
Item I: Enter the Customer’s choice for authorized representatives, and if applicable, the name and contact information of the
authorized representative.
FAA DETERMINATION: The FAA worker checks the applicable determination: Approved, Denied or Stopped.
Approved: Enter the Medical Assistance Category, effective date, and the date notice was sent to the Customer.
Denied: Enter the reason, the effective date, and the date notice was sent to the Customer.
Stopped: Enter the reason, the effective date, and the date notice was sent to the Customer.
III. Routing: (fax or secure e-mail)
Tribal Social Services keeps a copy for their case file and routes the original to FAA.
FAA returns completed original to Tribal Social Services, and keeps a copy in the FAA case file.
ACCEPTABLE PROOF DOCUMENTS (Examples)
CITIZENSHIP [List of document(s)]
QUALIFIED NON-CITIZEN STATUS
U.S. passport or passport card
Immigration documents
Naturalization certificate, form N-550 or N-570
Court documents
Certificate of U.S. Citizenship, form N-560 or N-561
Income
Document issued by a federally recognized Indian Tribe
Paystubs
Certified birth documents
Documented collateral contact by social worker
Church records
Written statement from employer
Baptismal certificates issued prior to child’s fifth birthday
Award letters
Hospital records
Current tax returns for self-employment
Court documents/minute entries
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