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FAA-1004A Designation of EBT Alternate Card Hold

FAA-1004A Designation of EBT Alternate Card Hold 2025

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The document is a form from the Arizona Department of Economic Security's Family Assistance Administration, allowing individuals to designate or remove an alternate card holder for accessing their Nutrition Assistance and Cash Assistance benefits. It includes sections for personal information, certification of designation, and civil rights information regarding non-discrimination policies.

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Click ‘Get Form’ to open the FAA-1004A in the editor.
Begin by entering your Case Name (Last, First, M.I.) and EI’s Name in the designated fields.
Fill in your Case Address, including No., Street, City, State, and ZIP Code.
Input your Case Number in the appropriate field.
Check the box to designate an EBT Alternate Card Holder. Enter their name and birthdate accurately.
If applicable, check the box to remove an existing EBT Alternate Card Holder and provide their name.
Sign as the Primary Informant and date your signature to finalize the form.
For case worker use, ensure that all necessary signatures are completed for processing.

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2021	4.1 Satisfied (60 Votes)
2018	4.7 Satisfied (238 Votes)

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