Form FAA-1353A "Affidativ Attesting Citizenship for Cash Assistance and Nutrition Assistance" - Arizona

What Is Form FAA-1353A?

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 March 1, 2018;
  • 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-1353A 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-1353A "Affidativ Attesting Citizenship for Cash Assistance and Nutrition Assistance" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-1353A FORFF (03-18)
Page 1 of 1
Family Assistance Administration
AFFIDAVIT ATTESTING CITIZENSHIP FOR
CASH ASSISTANCE AND NUTRITION ASSISTANCE
Case Name
Case Number
Citizen’s Name
Citizen’s Date of Birth
This form can be used only when other documents that verify the person’s citizenship cannot be obtained.
This form must be completed by a person meeting ALL of the following:
• Must be a United States citizen.
• Cannot be applying or receiving Nutrition Assistance and/or Cash Assistance benefits with the citizen.
• Must have personal knowledge of the person’s claim of U. S. citizenship.
By swearing and signing below, I attest that I am a U. S. citizen and can provide documentation to establish that I am a
U. S. citizen, if asked. I also attest that I am verifying the citizenship of
My relationship is that of a
I further attest, based on personal knowledge, that this person is a citizen of the United States based on:
Birth was on:
At:
Naturalization was on:
At:
Other: (Explain)
By signing below, I swear and declare under penalty of perjury that the statements I have given on this form are true
and correct to the best of my knowledge. I also understand that if I withhold information or provide or assist another in
providing false, fraudulent, or misleading information, I may be subject to civil and/or criminal prosecution resulting in fines,
imprisonment and/or repayment for costs of all benefits improperly received.
Name (Last, First, M.I.)
Phone NO. (Include area code)
Address (No., Street)
City
State
ZIP Code
Signature
Routing: Original – Case Record; Copy – Client
The USDA is an equal opportunity provider and employer. • DES/TANF Agencies are Equal Opportunity Employers/Programs•
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. Disponible en español en línea o en la oficina local.
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-1353A FORFF (03-18)
Page 1 of 1
Family Assistance Administration
AFFIDAVIT ATTESTING CITIZENSHIP FOR
CASH ASSISTANCE AND NUTRITION ASSISTANCE
Case Name
Case Number
Citizen’s Name
Citizen’s Date of Birth
This form can be used only when other documents that verify the person’s citizenship cannot be obtained.
This form must be completed by a person meeting ALL of the following:
• Must be a United States citizen.
• Cannot be applying or receiving Nutrition Assistance and/or Cash Assistance benefits with the citizen.
• Must have personal knowledge of the person’s claim of U. S. citizenship.
By swearing and signing below, I attest that I am a U. S. citizen and can provide documentation to establish that I am a
U. S. citizen, if asked. I also attest that I am verifying the citizenship of
My relationship is that of a
I further attest, based on personal knowledge, that this person is a citizen of the United States based on:
Birth was on:
At:
Naturalization was on:
At:
Other: (Explain)
By signing below, I swear and declare under penalty of perjury that the statements I have given on this form are true
and correct to the best of my knowledge. I also understand that if I withhold information or provide or assist another in
providing false, fraudulent, or misleading information, I may be subject to civil and/or criminal prosecution resulting in fines,
imprisonment and/or repayment for costs of all benefits improperly received.
Name (Last, First, M.I.)
Phone NO. (Include area code)
Address (No., Street)
City
State
ZIP Code
Signature
Routing: Original – Case Record; Copy – Client
The USDA is an equal opportunity provider and employer. • DES/TANF Agencies are Equal Opportunity Employers/Programs•
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. Disponible en español en línea o en la oficina local.