Fa 100 request 2026

1. Click ‘Get Form’ to open the FA-100 request in the editor.
2. Begin by entering your customer information. Fill in your name, social security number, case number, address, city, state, ZIP code, and phone number.
3. Indicate which programs you are appealing by checking the appropriate boxes for Cash Assistance, Nutrition Assistance, AHCCCS Health Insurance, or Tuberculosis Control.
4. Specify the reason for your appeal by checking the relevant box. Provide additional details in the 'Reason(s) Why I Don’t Agree With Your Decision' section.
5. If applicable, indicate whether you need an interpreter or accommodations for a disability by selecting 'Yes' or 'No' and providing further explanation if necessary.
6. Decide if you want to keep receiving benefits during your appeal process by checking one of the options provided.
7. Finally, print or type your name and sign the form before submitting it through our platform.

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