Form FAA-0620A "Treatment Center Change Report" - Arizona

What Is Form FAA-0620A?

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 December 1, 2020;
  • 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-0620A 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-0620A "Treatment Center Change Report" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-0620A FORFF (12-20)
Page 1 of 3
Family Assistance Administration
TREATMENT CENTER CHANGE REPORT
Center’s Name:
Center’s Phone No.:
Date of Report:
Center’s Address:
Authorized Representative’s Name:
Signature:
DATE EBT
DATES
PROGRAMS
PARTICIPANT’S NAME AND
ESTIMATED
BALANCE OF
CARD
IS THE PARTICIPANT
RESIDENT
APPLIED
DATE OF BIRTH
AZTECS
END OF
NA / CA
RETURNED
WORKING?
ENTERED
FOR OR
(Include new address, when
CASE NO.
TREATMENT
CREDITED TO
TO FAA OR
ENTER START AND
/ LEFT
PARTICIPATED
applicable
DATE
EBT ACCOUNT
GIVEN TO
END DATES
CENTER
IN
PARTICIPANT
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
See page 3 for EOE/ADA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-0620A FORFF (12-20)
Page 1 of 3
Family Assistance Administration
TREATMENT CENTER CHANGE REPORT
Center’s Name:
Center’s Phone No.:
Date of Report:
Center’s Address:
Authorized Representative’s Name:
Signature:
DATE EBT
DATES
PROGRAMS
PARTICIPANT’S NAME AND
ESTIMATED
BALANCE OF
CARD
IS THE PARTICIPANT
RESIDENT
APPLIED
DATE OF BIRTH
AZTECS
END OF
NA / CA
RETURNED
WORKING?
ENTERED
FOR OR
(Include new address, when
CASE NO.
TREATMENT
CREDITED TO
TO FAA OR
ENTER START AND
/ LEFT
PARTICIPATED
applicable
DATE
EBT ACCOUNT
GIVEN TO
END DATES
CENTER
IN
PARTICIPANT
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
See page 3 for EOE/ADA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FAA-0620A FORFF (12-20)
Page 2 of 3
Family Assistance Administration
TREATMENT CENTER CHANGE REPORT
DATE EBT
DATES
PROGRAMS
PARTICIPANT’S NAME AND
ESTIMATED
BALANCE OF
CARD
IS THE PARTICIPANT
RESIDENT
APPLIED
DATE OF BIRTH
AZTECS
END OF
NA / CA
RETURNED
WORKING?
ENTERED
FOR OR
(Include new address, when
CASE NO.
TREATMENT
CREDITED TO
TO FAA OR
ENTER START AND
/ LEFT
PARTICIPATED
applicable
DATE
EBT ACCOUNT
GIVEN TO
END DATES
CENTER
IN
PARTICIPANT
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Yes
No
NA
NA
/
CA
CA
Completion Instructions for FAA-0620A
FAA-0620A FORFF (12-20)
Page 3 of 3
TREATMENT CENTER CHANGE REPORT
A. Purpose: For the Rehabilitation Center’s representative to report information for all center residents who participated in an FAA benefit program during the
reporting period.
B. Completion: All items are self-explanatory.
Important:
Any dollar balance(s) of Nutritional Assistance (NA) / Cash Assistance (CA) credited to the participant’s EBT account must be listed separately.
Any change(s) in the designation of an authorized representative requires notice to FAA.
This report is due to the FAA on a weekly basis when there have been changes.
C. Routing: The center will email a copy to the FAA Policy Support Team.
D. Retention: The center retains the original for two years or until all issues are resolved, based on reported information.
This institution is an equal opportunity provider.
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.
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