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Get Az Fa-100 2018-2024

Ants an Appeal Case NO: Mail Drop: Date Received: CUSTOMER INFORMATION Name (Last, First, M.I.) SOC SEC NO Case No Address (No., Street) City State ZIP Code Phone Number (Include area code) I WANT AN APPEAL FOR THE FOLLOWING PROGRAMS: (CHECK BOX) Cash Assistance Nutrition Assistance AHCCCS Health Insurance Tuberculosis Control I WANT AN APPEAL BECAUSE I DO NOT AGREE WITH: (CHECK BOX) End of Benefits Amount of Benefits Denial of Application Overpayment Other (Explain): Reason(s) Wh.

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