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Get Arizona Hearing Request 2015-2024

Wing ONLY if you want a Fair Hearing Customer Information NAME (Last, First) SOC. SEC. NO. CASE NO. ADDRESS (No., Street, City, State, ZIP) PHONE NO. (Include area code) I Want a Fair Hearing for the following program(s): (Check Box) Cash Assistance Nutrition Assistance AHCCCS Health Insurance Tuberculosis Control I Want a Fair Hearing because I do not agree with: (Check Box) End of Benefits Amount of Benefits Denial of Application Overpayment Other (Explain): REASON(S) WHY I DISAGR.

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