Department of Economic Security

Family Assistance Administration

P.O. Box 19009 Case Number: 05905042
Phoenix, AZ 85005 Notice Number: X027
Notice Date: November 29, 2024
Program: Nutrition Assistance (NA)
Jon Lewis
Apt 40
6340 S Santa Clara Ave
Tucson, AZ 85706

NUTRITION ASSISTANCE (NA) MID APPROVAL CONTACT

Dear Jon Lewis,

THIS IS A REMINDER TO COMPLETE YOUR MID-APPROVAL CONTACT

We did not get your Mid Approval Contact or the Mid Approval Contact you gave us was not complete.

YOUR NEXT STEP

Complete a Mid-Approval Contact by December 09, 2024.

WAYS TO COMPLETE THE MID-APPROVAL CONTACT

Online:
myfamilybenefits.azdes.gov.
Call:
1 (855) 432-7587, Monday – Friday 7:00 am – 6:00 pm.
The TTY/TDD number for the hearing impaired is 7-1-1.
Mail:
Department of Economic Security
P.O. Box 19009
Phoenix, AZ 85005-9009
Fax:
Area codes 602, 480, or 623 fax to (602) 257-7031, toll-free if faxing
For all other area codes, fax to 1 (844) 680-9840.
In-person at any Department of Economic Security, Family Assistance Administration office.

CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
Page 1 of 8
 Summary of Current Information
Please review the information below before answering the questions on page 3.

1. Current Residential Address:

If blank, refer to question 1 on page 3

and provide an update.

2. Who is included in the household: 01

See question 2 below.

3&4. Income Source / Monthly Amounts: NO REPORTED INCOME SOURCES. PROVIDE UPDATES IN
QUESTIONS 3 AND 4 ON PAGE 3.
See questions 3 and 4 below.

5. Child or Medical Support you are Child/Medical Support: $ 0

paying.
See question 5 below.

CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
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 Mid-Approval Contact Form

Please answer all questions. Case Number: 05905042

If you had a change that you have not told us about, check YES.
If you did not have a change OR if you had a change that you have told us about, check NO.
YES NO
1. Did you have a change in your residential address?
If Yes, complete Section 1 below
2. Has anyone moved into or out of your home?
If Yes, complete Section 2 below
3. Has a source of income changed for anyone in your home?
If Yes, complete Section 3 below
4. Have there been any changes of $125 or more in the
amount of money or income your household gets?
If Yes, complete Section 4 below
5. Have there been any changes in court ordered child support,
or court ordered medical support your household is paying?
If Yes, complete Section 5 below
6. Has anyone in your household received lottery or gambling
winnings of $4500 or more in a single game?
If Yes, complete Section 6 below

By signing below: I attest to the truthfulness of the information provided and that I understand with
any reported change my benefits may be increased, decreased, or stopped.
Printed name of Client/Authorized Signature of Client/Authorized Date
Representative: Representative:

CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
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If you answered YES to any of the questions above, please give us more information by completing the
section below about your change.
Please give us proof of any changes that you list below.

SECTION 1 - ADDRESS CHANGED

Date Moved: __________________
Residential Address (No., Street, City, State, ZIP Code):
____________________________________________________________________________________
Mailing Address, if different (P.O. Box, Apt./Space #/ No., Street, City, State, ZIP Code):
____________________________________________________________________________________
List your new shelter and utility expenses below:
Expense Type Who Pays Amount How Often
__________________ ________________________ $________________ ___________________
__________________ ________________________ $________________ ___________________
__________________ ________________________ $________________ ___________________
__________________ ________________________ $________________ ___________________
__________________ ________________________ $________________ ___________________

How do you heat (central heating, stove, fireplace) or cool (air conditioning, evaporative cooler) your
home?
____________________________________________________________________________________

Landlord's name: ____________________________________________

Landlord’s phone number: ____________________________________

SECTION 2 - HOUSEHOLD MEMBERS CHANGED

List the household members that moved in and the date they moved in.
Name of Person Relationship Date Moved In
_________________________________ ___________________________ _____________
_________________________________ ___________________________ _____________
_________________________________ ___________________________ _____________
List the household members that moved out and the date they moved out.
Name of Person Relationship Date Moved Out
_________________________________ ___________________________ _____________
_________________________________ ___________________________ _____________
_________________________________ ___________________________ _____________

CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
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SECTION 3 - INCOME SOURCE CHANGED
List the household member names, sources of income, and what changed.
Name of Person Source What Changed
______________________________ _____________________ ____________________________
______________________________ _____________________ ____________________________
______________________________ _____________________ ____________________________

SECTION 4 - INCOME AMOUNT CHANGED

List the household member names, sources of income and the new amounts (if applicable, include hours
per week, rate of pay and how often paid).
Please give us proof of income for the most recent 30 days or proof that income has stopped.

Name of Person ________________________ Name of Person ________________________

Source Name ________________________ Source Name ________________________
Date Changed ________________________ Date Changed ________________________
Gross Monthly Amount __________________ Gross Monthly Amount __________________
Rate of Pay __________________________ Rate of Pay __________________________
Hours Worked per Week ________________ Hours Worked per Week ________________
How Often Paid ________________________ How Often Paid ________________________

SECTION 5 – CHILD SUPPORT EXPENSE CHANGED

List the household member who pays, how much, how often, and the name of the child for whom the
support is paid.
Name of Person Who Pays Amount How Often Name of Child
__________________________ _____________ ____________ _________________________
__________________________ _____________ ____________ _________________________
__________________________ _____________ ____________ _________________________

SECTION 6 – LOTTERY AND GAMBLING WINNINGS

List the information about the lottery and gambling winnings received in the amount of $4500 or more
in a single game.
Name of Person Amount Received Date Received How Much is Left
_________________________ _______________ _____________ ________________

CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
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WHAT TO EXPECT IF YOU DO NOT COMPETE THE MID-APPROVAL CONTACT
If you do not complete the Mid-Approval Contact or ask us for help, your NA benefits could be stopped.
We will send you a separate notice if we take further action.

WHO TO CONTACT IF YOU HAVE QUESTIONS

- Call 1 (855) 432-7587 Monday - Friday, 7:00 a.m. to 6:00 p.m.
The TTY/TDD number for the hearing impaired is 7-1-1.
- In person at any Department of Economic Security Family Assistance Administration office.

HOW TO REPORT CHANGES

- Call 1 (855) 432-7587 Monday - Friday, 7:00 a.m. to 6:00 p.m.
- The TTY/TDD number for the hearing impaired is 7-1-1.
- Online at www.healthearizonaplus.gov or myfamilybenefits.azdes.gov.
- Mail your change report to PO BOX 19009, Phoenix, AZ 85005.
- Fax your change report to (602) 257-7031 or toll free to (844) 680-9840.
- In person at any Department of Economic Security Family Assistance Administration office.

WHAT TO DO IF YOU DO NOT AGREE WITH THIS DECISION

You may appeal by:
- Filling out the Hearing Request form included with this notice and return it in person at any
Department of Economic Security, Family Assistance Administration office. Or fax to (602) 257-7058,
(602) 257-7056, or (602) 257-7055.
- You may call (602) 771-9019 or toll free at 1 (877) 525-9990.
- Mail your request to:
Department of Economic Security
P O Box 19009
Phoenix, AZ 85005-9009
- Go online to www.healthearizonaplus.gov and sign into your account.
You can request your benefits to continue pending an appeal, but you may have to pay back the benefits
you were not entitled to get.
_____________________________________________________________________________________
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex (including gender identity and sexual orientation), religious creed, disability, age,
political beliefs, or reprisal or retaliation for prior civil rights activity. Program information may be made
available in languages other than English. Persons with disabilities who require alternative means of
communication to obtain program information (e.g., Braille, large print, audiotape, American Sign
Language), should contact the agency (state or local) where they applied for benefits. Individuals who
are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a
Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at:
www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (833) 620-
1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name,
address, telephone number, and a written description of the alleged discriminatory action in sufficient

CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
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detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged
civil rights violation. The completed AD-3027 form or letter must be submitted to: mail: Food and
Nutrition Service, USDA 1320 Braddock Place, Room 334, Alexandria, VA 22314; or fax: (833) 256-1665
or (202) 690-7442; or mail: [email protected]
This institution is an equal opportunity provider.
_____________________________________________________________________________________
Este aviso se refiere a la información importante acerca de sus beneficios, los plazos cortos para pedir
una Audiencia y la manera de seguir recibiendo beneficios si usted está en desacuerdo con nuestra
decisión. Llame de inmediato al DES al 1 (855) 432-7587 y DES le leerán este aviso a usted en español.

CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
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CASE NAME: JON LEWIS CASE NUMBER: 05905042 DATE OF NOTICE: 11/29/2024
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