TP

ARIZONA DEPARTMENT OF ECONOMIC SECURITY (DES) 
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)

 
CUSTOMER NAME: DATE: HEA PLUS PERSON ID: APPLICATION ID:
KRISTOPHER BALDWIN 05/30/2017 39903843336157 2017149088454

Call 1­855­HEA­PLUS (432­7587) if you have any
KRISTOPHER BALDWIN questions or need help.
2929 W RANCHO DR
PHOENIX AZ 85017­2554

Request for Information 

Dear KRISTOPHER BALDWIN  
 
We need the information listed below to decide if you can qualify for the programs for which you have applied. Contact us if you have trouble
getting the information we are requesting. We may be able to help.
 
You must give us this information no later than 06/14/2017. There are several ways for you to give us the information we are asking for below:

1.  Log in to your Health­e­Arizona Plus account at 'https://www.healthearizonaplus.gov/' to scan, upload, or email information.
OR
2.  Fax your information using the attached fax coversheet to 1­888­372­8777. The fax coversheet has a barcode that identifies your case.
OR
3.  Mail your information to: Department of Economic Security, P.O. Box 19009, Phoenix, AZ 85005­9009

If you cannot get this information to us by the due date, you may be able to get more time. You can request more time by calling the number above.
 
If we do not get the information and we do not hear from you, we will deny your application or stop/change your benefits.
 

Page 1 of 3  
 CUSTOMER NAME: DATE: HEA PLUS PERSON ID: APPLICATION ID:
Kristopher Baldwin 05/30/2017 39903843336157 2017149088454

­ Nutrition Assistance     
 

Required
Please give us... by
We need to verify... Note: The following are common examples of the 06/14/2017
documents and information that we can use. Please for
send any proof you have, even if it is not listed in these
examples.

Social Security number for  The Social Security number that you gave us does not match records X
from the Social Security Administration.  Give us one of the following:
Kristopher Baldwin (Birthdate: 08/15/1991; Person
ID: 39903843336157; AHCCCS ID: A95180549) A copy of the Social Security Card,
A copy of the SSI or SSA benefit award letter. or
A letter from the SSA verifying your Social Security number.

U.S. Citizenship for  We were not able to verify citizenship status using electronic sources. X
Give us a copy of a document showing proof of U.S. citizenship, such
Kristopher Baldwin (Birthdate: 08/15/1991; Person as:
ID: 39903843336157; AHCCCS ID: A95180549)

U.S. passport,
Naturalization Certificate,
Certificate of U.S. Citizenship,
Enhanced drivers license; or
Document issued by a federally recognized Indian Tribe.
U.S. Birth Certificate
Certificate of Birth Abroad (FS­545 or DS 1350)
Report of Birth Abroad (FS­240)
Certification of birth issued by the Department of State (Form
FS­545)
U.S. Citizen ID card (I­197 1­179)
Northern Mariana ID Card (I­873)
American Indian Card (I­872)
Final adoption papers listing the child’s name and a U.S. place
of birth
Evidence of U.S. Civil Service employment before June 1, 1976
U.S. Military Record showing a U.S. birthplace
Extract of U.S. hospital record of birth on hospital letterhead
Federal or State census records with the person’s name, U.S.
citizenship, a U.S. place of birth, and date of birth or age
One of the following documents if it was created at least 5 years
before the person first applied and shows birth in the U.S. For
children under 16 it must have been created near the time of
birth or 5 years before the date of application

1.  Life, health or other insurance record
2.  Medical record
3.  Admission papers from a nursing home or other institution
4.  Bureau of Indian Affairs tribal census record of the Navajo
Indians
5.  U.S State Vital Statistics official notification of birth registration

Page 2 of 3  
 CUSTOMER NAME: DATE: HEA PLUS PERSON ID: APPLICATION ID:
Kristopher Baldwin 05/30/2017 39903843336157 2017149088454

6.  A delayed U.S. public birth record
7.  Statement signed by the physician or midwife in attendance at
the birth
8.  Roll of Alaska Natives maintained by the Bureau of Indian Affairs

Early school records that show ALL of the following: name, date
admitted to the school, date of birth, a U.S. place of birth, and
the parent’s name and birthplace.

Affidavit for U.S. Citizenship The attached “Affidavit Attesting Citizenship” form must be completed X
and signed by someone who:

Is a U.S. citizen

Has knowledge of your citizenship, and

Is not applying for or getting benefits with you.

Page 3 of 3  
 CUSTOMER NAME: DATE: HEAPLUS PERSON ID: APPLICATION ID:
Kristopher Baldwin 05/30/2017 39903843336157 2017149088454

AFFIDAVIT ATTESTING CITIZENSHIP FOR

CASH ASSISTANCE AND NUTRITION ASSISTANCE
CITIZEN’S NAME CITIZEN’S DATE OF BIRTH

This form can be used only when other documents that verify the person’s citizenship cannot be obtained.
This form must be completed by a person meeting ALL of the following:
 Must be a United States citizen.
 Cannot be applying or getting Nutrition Assistance and/or Cash Assistance benefits with the citizen.
 Must have personal knowledge of the person’s claim of U. S. citizenship.

By swearing and signing below, I attest that I am a U. S. citizen and can provide documentation to establish that I am a

U. S. citizen, if asked. I also attest that I am verifying the citizenship of

My relationship is that of a
I further attest, based on personal knowledge, that this person is a citizen of the United States based on:

Birth was on: at:

Date Place

Naturalization was on: at:

Date Place

Other: (explain)

By signing below, I swear and declare under penalty of perjury that the statements I have given on this form are
true and correct to the best of my knowledge. I also understand that if I withhold information or provide or assist
another in providing false, fraudulent, or misleading information, I may be subject to civil and/or criminal prosecution
resulting in fines, imprisonment and/or repayment for costs of all benefits improperly received.
PRINTED NAME PHONE NUMBER (Include area code)

ADDRESS (No., Street, Apartment, City, State, ZIP)

SIGNATURE
 2017149088454
Kristopher Baldwin 05/30/2017

2929 W Rancho Dr, Phoenix, Arizona, 85017-2554

(H)(480) 316-8577, (C)(602) 369-8016

1-888-372-8777 OR 1-916-621-2795

SSN (Kristopher Baldwin )

US Citizen (Kristopher Baldwin )

2017149088454
2017149088454
Kristopher Baldwin 05/30/2017

2929 W Rancho Dr, Phoenix, Arizona, 85017-2554

(H)(480) 316-8577, (C)(602) 369-8016

1-888-372-8777 OR 1-916-621-2795

NO TEMPORARY DOCUMENTS REQUIRED

2017149088454