EXHIBIT A HEAF POLICY MANUAL FY2019.PDF

Arizona Community Action Association
Home Energy Assistance Fund
Policy Manual
FY 2019
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Table of Contents
Mission ...................................................................................................................................... 4
Purpose and Principles ............................................................................................................... 4
Fund Sources Currently In Distribution ....................................................................................... 4
Target Population ...................................................................................................................... 4
Intake and Application ............................................................................................................... 4
Grants Management System (GMS) ............................................................................................ 5
Household Eligibility .................................................................................................................... 5
Frequency of Assistance ...................................................................................................................... 5
Household Members ........................................................................................................................... 6
Household Income .............................................................................................................................. 6
Income Eligibility ................................................................................................................................. 6
Condition of Crisis ............................................................................................................................... 6
Applicable crisis reasons ................................................................................................................. 7
Document Verification ................................................................................................................ 7
Identity Verification............................................................................................................................. 7
Identity Verification Documents ...................................................................................................... 7
Citizenship Verification (URRD and HEAF only) .................................................................................... 8
Income Verification ............................................................................................................................. 8
Countable Income Sources .............................................................................................................. 8
Excludable Income Sources ............................................................................................................. 8
Steps to Calculate and Verify Household Income ............................................................................. 9
Payment Guarantee Process ...................................................................................................... 9
Information Included in Payment Guarantee Requests .................................................................... 9
Agency Reimbursement Process ................................................................................................ 9
Record Keeping ......................................................................................................................... 10
Case Files .......................................................................................................................................... 10
Documents Included in Case Files .................................................................................................. 10
Maintaining Records ......................................................................................................................... 11
Payments Made to Ineligible Households .................................................................................. 11
Fraudulent Information and Conflict of Interest ........................................................................ 11
Relatives of Applicants ...................................................................................................................... 11
Agency Employees ............................................................................................................................ 11
Policy Changes and Clarifications .............................................................................................. 11
Distributing Funds and Monitoring Balances ............................................................................. 12
Monitoring/Audit Process ......................................................................................................... 12
Cooperation .............................................................................................................................. 12
Confidentiality........................................................................................................................... 12
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Non-Discrimination Policy ......................................................................................................... 13
Appeals Policy ........................................................................................................................... 13
Appendix A: Countable and Excludable Income ......................................................................... 14
Appendix B: Instructions for Verifying Citizenship and Non-Citizen Legal Permanent Resident
(LPR) Status ............................................................................................................................... 21
ATTACHMENT 1: PAYMENT GUARANTEE CONTACT INFORMATION ......................................... 34
ATTACHMENT 2: PROGRAM SUMMARIES................................................................................ 36
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Mission
The Home Energy Assistance Fund (HEAF) at ACAA develops and coordinates resources through
education, advocacy, financial assistance, and local partnerships throughout the state of
Arizona to help families meet their basic energy needs and move toward economic stability.
Purpose and Principles
This fund has been established to provide assistance to Arizona households needing assistance
in managing their energy burdens. The purposes of the fund include:
 Alleviate crisis situations by preventing disconnection and/or facilitating
reconnection of utility services
 Supplement currently existing energy assistance resources
 Identify new/additional sources of support
Fund Sources Currently In Distribution
 APS Crisis Bill Assistance  Global Water LIRT
 SRP Bill Assistance  TEP Bill Assistance
 Southwest Gas LIEC  UNS Gas & Electric Warm Spirit
 Southwest Gas Energy Share – Fund
Bill Assistance  Utility Repair, Replacement and
 Southwest Gas Energy Share – Deposit
Repair/Replacement  Home Energy Assistance Fund
Target Population
Individuals and families throughout the state of Arizona, who find themselves in a position of
economic crisis, are encouraged to seek assistance from a community partner organization with
access to these funds.
Local organizations under contract with ACAA to distribute these funds are encouraged to
provide outreach services to increase awareness of this program among the target population
who reside within the borders of their service area, including Native Americans living on tribal
reservations.
Intake and Application
Local partner agencies should utilize efficient and accessible intake processes while serving
clients at sites that are geographically accessible to all households in their service areas. An
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appropriate intake/application form is recommended for use in the intake process to facilitate
prescreening and client data gathering.
Agencies should also provide low-income individuals who are not able to travel to the intake
site the means to submit an application without leaving their residences. Reasons for inability
to travel might include illness or disability, caregiving duties, or other such circumstances.
Grants Management System (GMS)
Appropriate data provided by clients in the application process must be entered into the Grants
Management System (see the GMS User Manual) at the time of application or on a monthly
basis by way of a pre-arranged, data integration process.
Monthly transfers of applications from partner agencies utilizing the data integration process
must be received by the 10th day of the month, following any activity in the previous month.
All partner agencies must ensure that, by the 15th day of the month, applications in GMS from
the previous month reflect accurate and complete information.
Repair/Replace jobs may take longer than the 15th day of the following month; however,
expenditures should be entered into GMS as soon as they occur. If other fund sources are
utilized, it is not necessary to wait until the entire job is completed to enter expenditures into
GMS.
Household Eligibility
Specific eligibility requirements for utility assistance vary by fund source. Comprehensive
outlines for these fund sources can be found in the Program Summaries attached to the end of
this document (see Attachment 2). The following eligibility topics apply to all fund sources.
Frequency of Assistance
Each household may only receive assistance from a particular fund source once in a 12-month
period. Clients may return within that timeframe to seek additional assistance, but are not
eligible to receive assistance from the same fund source more than once in a 12-month period,
unless otherwise specified by the program summary of the fund source. Please note that
current and past-due charges of the same fund source may be combined, but should not
exceed the maximum fund source amount.
Agencies using GMS can determine whether a client has been served by a different agency in
the same year.
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Household Members
Each person living in the home is considered a household member. Income level and eligibility
will be determined based on the entire household, including roommates. Boarders, not related
by blood or law to the homeowner, are not considered household members for purposes of
eligibility determination.
For clarification, boarders pay rent to someone living in the same home, while roommates pay
rent to someone living outside the home. Income from each roommate is counted toward total
household income, while income from boarders is not.
Household Income
All income for household members 18 years of age and older must be counted toward total
household income, as well as the income of all household members 16 and 17 years of age who
do not attend school full time.
In cases of domestic violence, the income and resources of the abuser are not counted as long
as the client does not have access to the abuser’s income and resources.
Income Eligibility
Each fund source specifies an income threshold for households seeking assistance. These
thresholds are based on either the Federal Poverty Level (FPL) guidelines or the State Median
Income (SMI) guidelines. Updated information outlining these guidelines will be attached to
community partner contracts and should be adhered to throughout the entire fiscal year.
Condition of Crisis
When required by the fund source, eligible clients must be experiencing a crisis in order to
qualify for services. There is no required timeframe wherein the crisis must have occurred. If a
crisis reason is not clearly stated in the client file a client affidavit form should be used to allow
the client to attest to the validity of their crisis reason. The form must be signed by the client.
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Applicable crisis reasons
1. Loss or reduction of income or public assistance benefits or a delay in receiving
public assistance benefits.
a. Examples include: loss of employment, theft of income, serious illness which
causes a loss of income, divorce, abandonment or death of a wage earner,
reduction of benefits or public assistance monies.
2. Unexpected and/or unplanned expenses that cause a lack of resources.
a. Examples include: car repairs, medical bills, natural or man-made disasters,
death in the immediate family, court fines.
3. A condition that endangers the health and safety of the household.
a. Examples include: lead poisoning, condemned property, infestation,
domestic violence, asbestos, a medical condition that requires uninterrupted
utility service for life-saving equipment such as oxygen machines, heart
monitors, breathing machines, etc.
Document Verification
Identity Verification
The identity of the applicant must be verified before services can be provided. Any of the
documents listed below can be used for identity verification.
Identity Verification Documents
1. Driver’s license
2. Work or school ID
3. ID card from health benefits or social service program
4. Social Security card
5. Voter registration card
6. Wage stubs
7. Birth certificate
8. Family census card
9. Other reasonable sources
In addition, the utility service address must be verified to match the applicant’s residential
address.
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Citizenship Verification (URRD and HEAF only)
The Utility Repair Replacement Deposit (URRD) and the Home Energy Assistance Fund (HEAF)
both require that the primary applicant be verified as a U.S. Citizen or Legal Permanent
Resident. Information concerning this verification process and a list of all federally accepted
documents can be found in Appendix B of this document.
Income Verification
In order to determine the eligibility of applicants, all household income must be accounted for
and verified. The most recent 30 days (up to and including the day of application) of countable
income for each household member must be verified. This includes earned and unearned
amounts. In addition, gross income amounts (not net income) must be counted, unless
otherwise noted.
In cases where all attempts to obtain necessary income verification have failed, a client affidavit
form can be used to allow the client to attest to the validity of their income information. The
form must be signed by the client.
Some sources of income do not count against total household income. The following lists
include the most common sources of both countable and excludable income. For
comprehensive lists, please refer to Appendix A of this document.
Countable Income Sources
1. Earned income: employment, self-employment1
2. Benefit income: SSA, SSI, TANF-CA, VA, UI, GA,
3. Pensions
4. Worker’s compensation
5. Child support
6. Work study
7. Other unearned income: rental income, and endowments or legal settlements.
8. Indian gaming commissions
Excludable Income Sources
1. Food stamps
2. Medicare
3. WIC
4. AmeriCorps stipend
1 Net income will be counted for self-employment income (gross income less business related expenses).
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5. Earned income of a child under 16 years of age, or of a child that is 16 or 17 years of
age and is a full time student
6. Income tax refund
7. Cash gifts of $50 or less per month per household member
8. Insurance payments
9. Foster care payments and adoption subsidies
10. Housing and Urban Development (HUD) benefits.
Steps to Calculate and Verify Household Income
1. Identify the 30-day period prior to and including the application date.
2. Determine the number of sources of countable income received by all household
members during this 30-day period.
3. Determine the amounts of countable income received from each source for each
household member during this period.
4. Combine these amounts to reach the total, 30-day household income.
5. Compare this amount to the chosen fund source’s income threshold, based on the
number of household members.
6. Verify each amount from each income source using documents provided by the
client and preserve a copy of each document for the client’s file.
Payment Guarantee Process
Once a decision to approve a client’s application has been made and all documents have been
obtained and verified, a payment guarantee can be initiated on behalf of the client. Each fund
source has its own point of contact for receiving these guarantee requests. This information
can be found in Attachment 1: Payment Guarantee Contact Information. Payment guarantee
requests should include all of the information listed below.
Information Included in Payment Guarantee Requests
1. Account number
2. Customer name on account
3. Customer address
4. Date of guarantee and guarantee amount
5. Fund source (if possible)
6. Name of case worker requesting the guarantee
7. Name of organization requesting the guarantee
Agency Reimbursement Process
All guarantees and payments made by local partner agencies on behalf of clients are eligible for
reimbursement from ACAA on a monthly basis. These guarantees and payments must be
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accompanied by complete and accurate applications recorded properly in the Grants
Management System (GMS) in order to receive reimbursement from ACAA. See the GMS User
Manual for clarification on this process.
Agencies will receive reimbursement for the amounts guaranteed plus any service delivery
amounts, as specified in contract. Funds received for guarantees made are dedicated funds
only for the purpose of paying for the guarantees and must be paid to the respective utility
company as soon as possible. Funds received for service delivery have no restrictions and may
be used at the discretion of the agency.
Record Keeping
The applicant has the primary responsibility to provide all required documents. In situations
where it is difficult for the applicant to obtain documents needed to complete the eligibility
determination, the local partner agency should offer assistance to the client in obtaining the
information.
In cases where all attempts to obtain necessary documents have failed, a client affidavit form
can be used to allow the client to attest to the validity of any eligibility information provided.
The form must be signed by the client. The affidavit cannot be used to verify U.S. citizenship or
legal permanent resident status.
Case Files
Supporting documentation for each client application must be kept in individual case files. Each
file must contain all of the necessary documents to support the eligibility determination
decision reached by the agency. Case files for every fund source must contain the documents
listed below. Electronic records are sufficient.
Documents Included in Case Files2
1. Intake sheet with client info and name of caseworker
2. Verification document for ID of client
3. Citizenship verification of primary applicant (for HEAF and URRD only)
4. Utility bill (or receipts for purchases of fuel)
5. Income verification
6. Crisis documentation (if required by fund source)
7. Client affidavit form (if utilized)
8. Statement of truth and release of information form, signed by the client
9. Copy of completed payment guarantee request
2 Agencies may be granted reasonable exemptions from including certain documents in case files. Contact ACAA staff for
exemption requests.
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Additional documents may be required by certain fund sources when indicated on the fund
source program summary.
Maintaining Records
Local partner agencies are required to maintain supporting financial records, documentation,
and statistical records for three years.
Payments Made to Ineligible Households
If assistance is provided to an ineligible household due to a caseworker’s error, an over-
expended fund source, or if the client was found to be ineligible after the payment was made,
the award to the household must be honored and the partner agency will be responsible for
repaying the award amount to ACAA and paying the guarantee using funds other than those
provided to the agency by ACAA. The partner agency has the right to appeal any repayment
determination directly to ACAA.
Fraudulent Information and Conflict of Interest
If a client is found to be fraudulent in his/her application and the payment has not been sent to
the utility, the payment must be stopped and the client appropriately informed.
Relatives of Applicants
Caseworkers are not permitted to complete applications for their own relatives to the first-
cousin level including step and in-law relatives. Specifically parents, siblings, spouses, aunts,
and uncles are to be interviewed by another caseworker or supervisor. Upon request, and
when possible, ACAA staff may provide application intake.
Agency Employees
Agency employees should not be denied the right to apply for and receive services through this
program. These individuals or members of their households may apply for assistance; however,
a supervisor must conduct the application intake process. Upon request, and when possible,
ACAA staff may provide application intake.
Policy Changes and Clarifications
Revisions to any policies and procedures will be reviewed and approved by the ACAA Home
Energy Assistance Fund Advisory Board and the ACAA Board of Directors. All revisions will be
sent to local partner agencies as they occur. Partner agencies have the responsibility to update
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their own information as revisions are received. Issues regarding policy and/or procedures
must be submitted in writing.
Distributing Funds and Monitoring Balances
Local partner agencies are responsible for monitoring the ongoing balances of each fund source
under contract with ACAA, throughout the course of the contract year. All funds must be
distributed to eligible clients by the end of the contract year and over-expenditures must not be
allowed. Any over-expenditure incurred by the agency must be repaid to ACAA using funds
other than those provided to the agency by ACAA.
URRD invoices should be submitted at the time of completion of repair and replacement, even
if part of the larger weatherization job may not be finished. If crossing over into next fiscal year,
the URRD dollars become ineligible.
Monitoring/Audit Process
Partner agencies are responsible for ensuring that all policies and procedures are being
followed. ACAA staff will conduct an audit of application and case files during annual
monitoring visits. The following four, general elements are reviewed in every audit.
General Elements of an Audit
1. Accuracy of information
2. Client eligibility, based on the fund source utilized
3. Completeness of the client file (all required documents included)
4. Timeliness and accuracy of the guarantee/payment process
Cooperation
Applicants must cooperate in all aspects of the application process. Applicants must provide
requested information or verification and complete and sign an application. If the applicant
refuses, the application will be denied. The partnering agency should document the lack of
cooperation by the applicant for proper notation in refusal of assistance.
Confidentiality
All information, regarding an applicant or recipient, is confidential and may be disclosed only
for purposes of determining eligibility, providing services, or investigating suspected fraud in
connection with the program. Applicants authorize access to their records by signing the
release of information form. Anyone not authorized on the application must have the
applicant's written approval to access information.
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Information that can be divulged must pertain to the eligibility of the applicant, and excludes
items that do not address eligibility, i.e. personal details. Inappropriate disclosure of
information can result in severe disciplinary action, or could result in the suspension of the
partnering agreement.
Access to information by inappropriate, unauthorized individuals or parties shall be considered
a violation of the individual's right to confidentiality. The Contractor shall take reasonable steps
to safeguard, secure and maintain the confidentiality of any and all individual information in its
possession, and to protect such information from unauthorized access, use or disclosure,
utilizing the same degree of care it uses to protect its own confidential information and, in no
event, less than a commercially reasonable degree of care. All records shall be open to any and
all federal, state, and contractor auditors and/or examiners in the course of their regular audits.
In the event that an agency receives a request to produce or disclose documents that contain
any confidential information pursuant to a valid public records request, or other applicable law,
order, or court ruling, the agency must promptly notify ACAA before honoring the request.
General information, policy statements, or statistical materials that cannot be directly identified
with any individual or family are not considered confidential. They may be given to, or provided
by: agencies, helping organizations, or contracted parties (unless restricted by Arizona statutes,
federal regulations, or court orders).
Non-Discrimination Policy
In compliance with Title VI of the Civil Rights Act of 1964 and Executive Order 12250, no
individual in Arizona shall be excluded from participation in, denied benefits from, or subjected
to discrimination under any program or activity receiving federal funds because of: race, color,
national origin, disability, religion, or sex, or sexual orientation.
In compliance with the Age Discrimination Act of 1975, no individual shall be denied services or
participation or be subjected to discrimination in any of its programs or activities on the basis of
age.
Appeals Policy
The client/agency has the right to appeal a denial of assistance or an awarded grant amount.
Appeals by the client must follow the policies of the intake partner agency and will be
addressed by ACAA administrative staff.
Complaints regarding the service of the administering agency, discrimination or other issues
directly related to the administering agency and staff must be addressed to the office where
the application was made.
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Appendix A: Countable and Excludable Income
Countable Income
EARNED and/or UNEARNED income will be considered in determining eligibility for services. The
gross amount of income prior to deductions will be counted unless otherwise specified.
Earned Income
Earned income is defined as either cash or in-kind income received as compensation for wages,
salaries, commissions or profit through employment or self-employment.
Earned income includes but is not limited to:
1. ARIZONA TRAINING PROGRAM (ATP): Salaries to handicapped persons working in a
sheltered workshop situation are counted. Verbal or written verification may be obtained
from ATP.
2. BABY-SITTING OR CHILDCARE INCOME: Earnings from baby-sitting are counted as self-
employment income. Verbal or written verification may be obtained from DES or the person
paying for the care.
3. CAN OR BOTTLE SALES OR OTHER USABLE DISREGARDS: Income from these sales is counted
as self-employment income. Client should have receipts for such sales. If receipts are not
available, a signed and dated client statement would be acceptable.
4. CONTRACT INCOME: Income received by individuals who are employed under a contract
that states a specific length of time and a specific income amount to be paid during that
time.
5. HOUSEKEEPER OR HOME HEALTH AIDES: Income earned as a housekeeper or home health
aide is countable. Verbal or written verification may be obtained from the employer.
Income is only counted once, if living in the household and paid by the applicant.
6. IN-KIND EARNED INCOME: Work performed by a client in exchange for room, board, or
other needs is earned in-kind income. The employer will establish the monetary value of the
service. A collateral contact or a signed and dated statement from the employer, or client
can verify in-kind income. The employer may be, but is not limited to:
a. A landlord who is providing rent or portions of the rent or utilities in exchange for
work.
b. A storeowner who gives goods, such as groceries, clothes or furniture in exchange
for work.
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c. An individual who receives a car, tools, trailer, building material, gasoline, etc. in
exchange for work.
7. JURY PAY: Counted as earned income. Check stubs should be available to verify income.
8. MILITARY INCOME: Wages received while in the military are countable. This includes: base
pay (BP), Proficiency pay (PRO), rations (separate/leave), basic allowance for housing (BAQ),
basic allowances for subsistence (BAS) and variable housing allowance (VHA) when
considered an entitlement. Use the leave and earnings statement, when available, to verify
the amount of earned income issued.
9. RENTAL INCOME: Any monies received from rental of property, including boarders, less
expenses, are counted as earned income if work is involved.
a. Work includes, but is not limited to, managing rental property requiring
maintenance, collection of rent or accounting functions. There is no time
requirement for number of hours worked.
b. If a person's income from rental of property does not require work, rent is
considered unearned income.
10. SELF-EMPLOYMENT INCOME AND EXPENSES: Self-employment includes but is not limited
to, businesses such as grocers, craftsmen, taking in boarders, ranching, farming, swap meet
sales, odd jobs, baby-sitting, can and bottle collection, janitorial, guide for hunting or fishing
or any wholesale or retail sales.
Clients are not considered self-employed if they work for a business or another person on a
commission basis, unless the client reports and pays his/her own withholding taxes for
state, federal and FICA.
Acceptable verification for self-employment is:
a. IRS Form 1099
b. Ledger statement
c. Client statement
When calculating self-employment income, the client may deduct any business expenses.
Gross incomes minus business expenses equals countable income.
11. VOCATIONAL REHABILITATION (VR): Wages from VR sponsored on-the-job training (OJT) are
countable.
12. WAGES: Gross earnings from employment, prior to any deductions, garnishments,
allowances or adjustments. Special benefits or deductions connected with employment
earnings are counted as follows:
a. Advances, bonuses and commissions must be counted as earned income in the
month received.
b. When tips are shown on the pay-stub and the household claims a lesser amount but
has no record of actual tips received, count the amount on the pay-stub.
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c. When tips are not shown on the pay-stub, obtain the individuals’ written tip record.
When not available, obtain a written statement from the household or contact the
employer.
13. WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA): Earnings from employment
through WIOA will be counted for persons age 18 and over.
14. WORK STUDY: Earnings received from the following: Work-study programs, when the funds
do not come under Title IV of the Higher Education Act; Veterans Administration work-study
program.
Unearned Income (countable)
Unearned income is defined as income, which was not received as a result of the performance of a
service, or earned from sources other than employment, self-employment or in-kind income.
Countable unearned income includes but is not limited to:
1. ALIMONY OR SPOUSAL MAINTENANCE: A court-ordered support amount, which a legally
divorced or separated person pays to the spouse, must be counted. Verbal or written
verification may be obtained from the office of the Clerk of the Court or Division of Child
Support Services.
2. ASSISTANCE PAYMENTS: such as General Assistance (GA) or Cash Assistance (CA) from this
state, as well as, other states must be counted.
3. BUREAU OF INDIAN AFFAIRS (BIA):
a. BIA-General Assistance payments are public assistance and treated as any other
assistance payments.
b. Clothing allowances available to the individual, whether in cash or a voucher made
out to the individual must be counted.
c. Tribal Work Experience Program (TWEP) or Tribal Assistance Project Program
(TAPP). Exclude any portion of the amount, which is an incentive payment.
4. CHILD SUPPORT: Any payment received directly by the household from an absent parent or
paid through the Division of Child Support Services or Clerk of the Court. Only the amount
paid to the client is counted (CP) = child support payment. All child support income is
considered unearned income.
5. COMMISSIONS: Commissions received from a terminated source of employment are
counted as unearned income.
6. CONTRIBUTIONS AND COMPLIMENTARY ASSISTANCE: Cash contributions must be counted
as unearned income, if not considered as gifts or child support.
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7. INDUSTRIAL COMPENSATION: The amount of the compensation, after attorney's fees are
deducted, is unearned income. The Industrial Claim award letter will verify amount being
paid but will not verify the attorney's fees.
8. INDIAN GAMBLING INDUSTRY: Per capita disbursements are considered income in the
month received. Any amount remaining in a following month will be counted as a resource.
9. INSURANCE: Insurance payments made directly to the insured must be considered income
IF the money is not used to replace or repair insured items, such as car, roof repair, or
medical bills. Insurance benefits, which are used for or are intended to meet basic daily
needs, are counted as unearned income.
10. INTEREST, DIVIDENDS, AND ROYALTIES: Any interest, dividend, or royalty payments,
exceeding $50 in the 30 days prior to and including date of application made directly to the
individual, are counted as unearned income. Funds left on deposit or converted into
additional securities are a resource.
11. LEGAL SETTLEMENTS: Legal settlements, less attorney fees and medical bills paid by the
attorney out of the settlement, are unearned income in the month received.
12. MORTGAGES AND SALES CONTRACTS: Payments received from mortgages or sales contracts
are counted. Includes payment received from a reverse mortgage.
13. LUMP SUM PAYMENT: Any form of income received in a lump sum payment, including but
not limited to:
a. Inheritance
b. Winnings from lotteries, bingo, or any other form of gambling
c. Insurance settlements including amount withheld as a lawyer’s fee
d. Property Tax Credit
e. Rebates/Credits
f. Refund Deposit
g. Severance Pay
14. RENTAL INCOME: If the property owner does not perform any services in order to receive
the income, it is unearned income.
15. RETIREMENT INCOME: The payments from retirement funds, pensions, and annuities must
be considered unearned income.
16. SOCIAL SECURITY ADMINISTRATION BENEFITS: SSA benefits (sometimes referred to as RSDI-
Retirement, Survivors, and Disability Insurance) are granted to eligible wage earners and/or
their dependents or survivors and are counted as unearned income.
17. SUPPLEMENTAL SECURITY INCOME (SSI): Monthly cash payments made under the authority
of Title XVI of the Social Security Act, as amended, to the aged, blind, and disabled (A
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Federally financed public assistance program). The recipient need not have contributed to
the Social Security Fund to be eligible for SSI benefits.
18. STRIKE PAY: from unions to striking employees is not wages and must be considered
unearned income. If there is no check stub, verification can be obtained by calling the union.
19. UNEMPLOYMENT INSURANCE (UI): Considered unearned income in the month received.
The amount of income can be verified by a check stub or contacting the local UI office.
20. VETERANS ADMINISTRATION BENEFITS (VA): Retirement, Survivors, Disability, and
Educational Benefits are paid to veterans and their dependents or survivors. Only the
amount of the benefit, which is actually received by the person whose income must be
included, will be counted.
Excludable Income
Only the income discussed in this section will be excludable:
1. Insurance payments designated to repay a specific bill, debt, or estimate, which cannot be
used for other needs, is not countable
2. WIC – Payments or benefits to persons participating in the WIC program (Special
Supplemental Food Program for Women, Infants, and Children) must be disregarded
3. Retirement, pension, and annuity interest/dividends are not countable as long as the money
cannot be withdrawn without penalty
4. Bureau of Indian Affairs (BIA) work-study program. This includes monies provided for
educational and living expenses
5. Work study programs funded under Title IV of the Higher Education Act
6. Any portion of an education grant or scholarship received by a household member
7. Earned income of a child 16 and 17 years of age who is a full time student
8. Earned income of a child under 16 years of age
9. Cash gifts of $50.00 or less per month per household member
10. Non-cash benefits provided on behalf of a household member but not paid directly in the
name of the household member, including but not limited to vouchers for food, clothing, or
housing
11. Loans that need to be repaid
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12. Money that a household member receives and uses for the care and maintenance of a
person who is not a household member
13. Payments/vouchers received by the household from the State for the health/well-being of a
foster child residing in the household
14. Stipends from senior companion programs – VISTA, Title II, Title V
15. Earned Income Tax Credit
16. Income Tax Refund
17. Reimbursements, e.g.; mileage, gas, lodging and meals
18. Agent Orange Payments
19. AmeriCorps Network Program payments for living allowances, earnings, and in-kind aid. The
AmeriCorps Network Program includes but is not limited to:
a. Arizona Conservation Corp
b. Arizona Council of Centers for Children and Adolescents (ACCCA)
c. Border Volunteer Corps (BVC), Mesa AmeriCorps Community Services
20. Partnership Rural Health Office, University of Arizona, Youth in Action, Learn and Serve
(NAU) Child Care Food Program payments
21. Disaster or emergency assistance provided by the Federal Disaster Relief Act or comparable
assistance provided by States, local governments and disaster assistance organizations
22. Housing and Urban Development (HUD) – Some individuals residing in HUD housing are
granted benefits either in the form of credits against their rent or as cash allowances. The
cash allowance must be used for the purpose intended, (rental or utility obligation)
23. Education and Employment: (a) Any wages, allowances, or reimbursement for
transportation and attendant care cost, unless accepted on a case-by-case basis, when
received by an eligible handicapped individual employed in a project under Title VI of the
Rehabilitation Act of 1973 as added by Title II of Public Law 95-602 (92 Stat.
24. Payments to members of specific Indian Tribes and Groups:
a. Settlement fund payments and the availability of such funds to members of the Hopi
and Navajo Tribes under section 22 of Public Law 93-531 (88 Stat. 1722) as amended
by Public Law 96-305 (94 Stat. 929) (Note: This exclusion applies to the income of
sponsors of aliens only if the alien lives in the sponsor's household.)
b. Any distributions of judgment funds to members of the San Carlos Apache Indian
Tribe of Arizona under section 7 of Public Law 93-134 (87 Stat. 468) and Public Law
97-95 (95 Stat. 1206) (Note: This exclusion applies to the income of sponsors of
aliens only if the alien lives in the sponsor's household.)
25. Adoption Subsidies/Reimbursements
19

Adoption Subsidy payments are federally, state, or locally funded assistance payments
provided to children with special needs. These payments are intended to help a child whose
special needs otherwise might hinder their adoption. Adoption Subsidy payments vary
depending on the special needs of the child. Adoption subsidy payments are NOT
COUNTABLE as income.
26. Other:
a. Compensation provided to volunteers by the Corporation for National and
Community Service (CNCS), unless determined by the CNCS to constitute the
minimum wage in effect under the Fair Labor Standards Act of 1938 (29 U.S.C. 201
et seq.), or applicable State law, pursuant to 42 U.S.C. 5044(f)(1) (Note: This
exclusion does not apply to the income of sponsors of aliens.)
b. Any assistance to an individual (other than wages or salaries) under the Older
Americans Act of 1965 as amended by Section 102 (h)(1) of Pub. L. 95-478 (92 Stat.
1515, 42 U.S.C. 3020a)
c. Amounts paid as restitution to certain individuals of Japanese ancestry and Aleuts
for losses suffered as a result of evacuation, relocation, and internment during
World War II, under the Civil Liberties Act of 1988 and the Aleutian and Pribilof
Islands Restitution Act, sections 105(f) and 206(d) of Public Law 100-383 (50 U.S.C.
App. 1989 b and c)
d. Payments made under section 6 of the Radiation Exposure Compensation Act, Public
Law 101-426 (104 Stat. 925, 42 U.S.C. 2210)
e. Payments made to individuals because of their status as victims of Nazi persecution
excluded pursuant to section 1(a) of the Victims of Nazi Persecution Act of 1994,
Public Law 103-286 (108 Stat. 1450)
f. Any matching funds from a demonstration project authorized by the Community
Opportunities, Accountability, and Training and Educational Services Act of 1998
(Pub. L. 105-285) and any interest earned on these matching funds in an Individual
Development Account, pursuant to section 415 of Pub. L. 105-285 (112 Stat. 2771)
g. Any earnings, Temporary Assistance for Needy Families matching funds, and interest
in an Individual Development Account, pursuant to section 103 of the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193, 42
U.S.C. 604(h)(4))
h. Payments made to individuals who were captured and interned by the Democratic
Republic of Vietnam as a result of participation in certain military operations,
pursuant to section 606 of the Departments of Labor, Health and Human Services
and Education and Related Agencies Appropriations Act of 1996 (Pub. L. 105-78)
i. Payments made to certain Vietnam veterans' children with spinal bifida, pursuant to
section 421 of the Departments of Veterans Affairs and Housing and Urban
Development, and Independent Agencies Appropriations Act of 1997 (Pub. L. 104-
204, 38 U.S.C. 1805(a))
j. Payments made to certain Vietnam veterans' children with spinal bifida, pursuant to
section 421 of the Departments of Veterans Affairs and Housing and Urban
Development, and Independent Agencies Appropriations Act of 1997 (Pub. L. 104-
204, 38 U.S.C. 1805(a))
20

Appendix B: Instructions for Verifying Citizenship and
Non-Citizen Legal Permanent Resident (LPR) Status
Definition of U.S. Citizenship
U.S. citizenship is established at birth when an applicant is born in the U.S., its territories, or
possessions. U.S. territories or possessions include any of the following:
 American Samoa
 Guam - on or after January 17, 1917
 Northern Mariana Islands-on or after November 4, 1986
 Panama Canal Zone –on or after February 26, 1904
 Puerto Rico - on or after July 1st, 2010 (Senate Bill 1182, Law #191 of 2009)
 Swain Islands
 U.S. Virgin Islands - on or after January 17, 1917
Verification of U.S. Citizenship
TO BE POTENTIALLY ELIGIBLE APPLICANTS WHO DECLARE U.S. CITIZENSHIP OR LEGAL RESIDENT
STATUS MUST PROVIDE DOCUMENTATION FOR VERIFYING, WITH THE FOLLOWING EXCEPTIONS:
The following participants are exempt if they are receiving the following services:
 Currently receiving Social Security Disability (SSD).
 Currently receiving Supplemental Security Income (SSI). This includes participants who move
here from another state and are in the process of transferring their SSI benefits to Arizona.
 Currently receiving Medicare.
 Eligible in the Deemed Newborn MA category.
 Children in Foster Care assisted under title IV-8 of the Social Security Act. Children who are
recipients of Foster Care maintenance or adoption assistance payments under title IV-e.
 Children receiving adoption subsidies.
Note: The participants receiving the service must provide an award letter or documentation as
proof of receiving the service. Once the participant is no longer receiving the benefits that meet the
exemption criteria they must then provide the proper and approved documentation as described in
the section below.
Approved Documentation
Citizenship may be verified using ANY of the documents indicated under sections A, B, C or D below:
A. Primary – Verification Documents
1. A birth certificate showing birth in the U.S., its territories or possessions.
21

2. Certificate of Birth issued by the Department of State (FS-545 or DPS-1350).
3. U.S. Passport current or expired, except limited passports which are issued for periods of
less than 5 years.
4. U.S. Passport Card issued by the United States Citizenship and Immigration Services
(USCIS).
5. Certificate of Naturalization (N-550 or N-570).
6. Certificate of U.S. Citizenship (N-560 or N-561).
7. Report of Birth Abroad of a U.S. Citizen (FS-240) issued by the U.S. State Department.
8. U.S. Consular officer's statement.
9. A United States Citizen Identification Card (I-197).
10. Northern Mariana Identification Card (I-873).
11. A tribal enrollment card or Certificate of Indian Blood issued by a federally recognized
Indian Tribe that shows that the person is enrolled or affiliated with that tribe.
12. American Indian Card (I-872) issued by USCIS with the classification code KIC. The benefit
granting Service Provider shall require the applicant to present a membership card or
other tribal document demonstrating membership in an Indian tribe. If the applicant has
no document evidencing tribal membership, the benefit granting Service Provider should
contact the Indian tribe for verification of membership.
22

B. Secondary – Verification Documents
1. An identification card for use of Resident Citizen (I-179).
2. U.S. Census record that shows the applicant's name, a U.S. place of birth and the date of
birth or the applicant's age when the record was made. It must also indicate a place of
birth in the U.S., its Territories or Possessions.
3. Religious record created within three months after birth, showing the participant's date of
birth, OR the participant's age when the record was made. It must indicate a place of birth
in the U.S. Territories or Possessions.
4. Proof of employment as a U.S. Government Civil Servant before June 1, 1976.
5. Early school records, showing the date of admission, the child's date and place of birth
and the names and places of birth of the parents.
6. Adoption finalization papers showing the child's name and place of birth in the U.S., its
territories or possessions. (When adoption is not finalized and the State will not release a
birth certificate prior to final adoption, a statement from a state approved adoption
Service Provider containing the child's name and place of birth may be used. The source of
information must be an original birth certificate and must be indicated in the statement).
C. Primary or Secondary Documents Are Not Available
When none of the primary or secondary documents are available, accept any other document that
establishes a U.S. place of birth or in some way indicates U.S. Citizenship. These include the
following:
1. Certificates of Live Birth signed by a hospital official and parent
2. Medical records created at least five years before applying for services that list a U.S.
place of birth (For children under age 16 the documents must be created near the time of
birth OR five years prior to the application date. These include: hospital wrist bands, crib
cards, or yellow copies of hospital birth certificates indicating birth in the U.S., its
territories or possessions (See U.S. Citizenship on page 1).)
3. American Indian Census Records
4. Verification from the U.S. Citizenship and Immigration Services (USCIS). (The
documentation CANNOT be expired.)
5. Verification from the Social Security Administration, e.g. award letter
6. Verification sent directly to the agency from a local, state or federal bureau of vital
records office
23

7. Legal records showing the applicant’s name and place of birth in the U.S., its territories or
possessions
8. Department of Homeland Security (DHS), Verification Information System (VIS) response
that validates U.S. Citizenship
9. Online data match screen print with the Arizona Department of Vital Records through the
AHCCCS Citizenship Verification System
10. Military papers - When verifying military service criteria, the following apply:
a. An honorably discharged veteran of the Armed Forces of the U.S. must present an
original or notarized copy of the veteran’s discharge papers
b. Verify active duty status with an original or notarized copy of the applicant’s
current orders or a military ID card (DD form 2(active))
c. A spouse or unwed dependent child of a veteran or active duty non-citizen must
provide a document to verify relationship along with military verification
requirements
d. A stepchild living with the stepparent must provide documents to verify
relationship along with military verification requirements
11. Marriage certificate showing marriage to a U.S. male citizen before September 22, 1922
12. Life, health or other insurance record, created at least five years before the application
date (Record must indicate a place of birth in the United States)
13. State census records that show the participant’s name, a U.S. place of birth, and the date
of birth or age of the participant
14. Tribal census records for the Navajo or Seneca tribes (The records must be created at least
five years before the application and list a U.S. place of birth.)
15. An official notification of birth registration from a U.S. State’s Department of Vital
Statistics
16. An amended U.S. public birth record that is amended more than five years from the
applicant’s birth
17. A statement signed by the physician or midwife who was in attendance at the time of
birth
18. The roll of Alaska Natives from the Bureau of Indian Affairs
19. A current decision letter from the ADES/Family Assistance Administration that
demonstrates eligibility for the Food Stamp or Cash Assistance Programs (The award letter
must list the Low Income Home Energy Assistance Program (LIHEAP) applicant as an
eligible member of the household and for Short Term Crisis Services (STCS) Program the
qualifying child must be listed as an eligible member of the household.)
24

D. Primary or Secondary Documents Not Obtainable
When the applicant cannot obtain the Primary or Secondary forms of verification they may provide
an Affidavit Attesting Citizenship. An Affidavit Attesting Citizenship must meet all of the following
requirements:
1. Be completed by a U.S. Citizen who is knowledgeable about the participant’s
circumstances
2. Be signed by a U.S. Citizen that is not a member of the household
3. Be approved by the Case Manager Supervisor
4. Document the reason for using the affidavit form
Only original or un-tampered copies of required documents are acceptable for verifying citizenship.
Verification of Qualified Non-Citizens
Applicants, who state they are Non-Citizen Legal Residents, must meet at least one of the
categories set forth below:
A. Lawful Permanent Resident (LPR)
A lawful permanent resident (LPR) is admitted into the U.S. for permanent residence under the
Immigration and Nationality Act (INA). This Non-Citizen Legal Resident is potentially eligible for
services when they meet any of the following:
1. They have been continuously lawfully residing in the U.S. and their date of entry is five
years in the past or more
2. They entered the U.S. as a Non-Citizen Legal Resident eligible for benefits in another
qualified category prior to becoming an LPR
3. They have a military connection
4. They are American Indians born in Canada who possess at least 50 per centum of
American Indian Blood. These Non-Citizen Legal Residents are recognized as LPR
These applicants normally have one of the following USCIS documents.
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED):
1. I-551- Resident Alien Card (Eligible for Benefits)
2. I-151- Alien Registration Receipt Card (Eligible for Benefits)
3. I-194- or unexpired passport with the words: Processed for I-551
25

Temporary Evidence of Lawful Permanent Residence – Valid Until (Date)
With the following Stamp/Annotations of Law
1. Adjustment Admission Stamp - Eligible when any of the following sections of law are
indicated: 203(a)(7); 207;208;212(d)(5); 243(h)(with a PRUCOL determination)
2. Non-Specific Admission Stamp -Eligible when the form is noted with an I- 551 eligible
status code
3. Parole Admission Stamp - Eligible when the period of parole is for at least one year as
verified on the stamp
4. Replacement Admission Stamp - Eligible when the stamp displays an I-551 eligible Status
Code
5. Temporary I-551 Admission Stamp - Eligible when the key phrase reads one of the
following:
a. "Admission for Permanent Residence at: “D" or "Processed for I-551 Temporary
evidence of admission for Permanent Residence" and displays one of the following
Status Codes: AM1; -2; -3; -6; -7; -8,
b. Asylee
i. An Asylee, Non-Citizen Legal Resident is granted asylum through an exercise
of discretion by the Attorney General, pursuant to Section 208 of INA. This
Non-Citizen is potentially eligible for benefits for a period of seven years
from the date their status is granted.
ii. These applicants normally have one of the following USCIS documents. (NOT
ACCEPTABLE IF DOCUMENTS ARE EXPIRED):
1. I-94 with one of the following:
a. A stamp showing grant of asylum under Section 208 of the
INA to include:
i. AS1 - Eligible for benefits
ii. AS2 - Eligible for benefits
iii. AS3V92 - Eligible for benefits
Note: The eligibility period begins from the month the Asylee status is granted,
NOT the month of U.S. entry.
B. Refugee or Amerasian
A Refugee or Amerasian is admitted into the U.S. under Section 207 of INA. This Non-Citizen is
potentially eligible for benefits for a period of seven years from the date that their status is granted.
These applicants normally have one of the following USCIS documents:
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED):
26

1. I-94- endorsed to show entry as a refugee under Section 207 of the INA or entry as an
Amerasian OR noted with one of the following Status Codes: NP2 – 7; P2 -6, -7, -71; RE-8;
Z2; (Eligible for Benefits).
C. Victim of Human Trafficking
A victim of human trafficking is admitted onto the U.S. under the Trafficking Victims Protection Act
(TVPA) of 2000. This Non-Citizen Legal Resident is potentially eligible for services for a period of
seven years from the date that their status is granted.
These applicants normally have one of the following USCIS documents:
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED)
1. I-94- with a T Visa or Derivative T Visa (T, T-2, T-3, T-4, or T-5)
D. Non-Citizen Legal Resident Paroled Into The U.S.
A Non-Citizen paroled into the U.S. is lawfully present in the U.S. as a result of a grant of parole by
the Attorney General, pursuant to Section 212(d) (5) of the INA. This Non-Citizen is potentially
eligible for services when the period of the parole is for at least one year.
These applicants normally have one of the following USCIS documents:
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED):
1. I-94 - with PAROLE PURSUANT TO SECTION 212(d) (5) on the front.
The form must not be expired and the expiration date must be at least one year after the issue
date. Both dates are documented on the form (Eligible for Benefits).
E. Non-Citizen Legal Resident Whose Deportation Is Withheld
A Non-Citizen Legal Resident whose deportation is withheld is a Non-Citizen Legal Resident for
whom the Attorney General has withheld deportation from the U.S. pursuant to Section 243(h) or
241 (b)(3) of the INA. A Non-Citizen Legal Resident whose deportation is withheld is potentially
eligible for services for a period of seven years from the date of the judge's orders.
These applicants normally have one of the following USCIS documents:
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED).
1. I-94 -with an order from an immigration Judge showing one of the following:
a. Deportation withheld under 243(h) of the INA (Eligible for Benefits)
b. Removal withheld under 241(b)(3) of the INA (Eligible for Benefits)
F. Cuban or Haitian Entrant
Cuban or Haitian entrants are admitted to the U.S. by USCIS as a Cuban or Haitian entrant pursuant
to Section 501 (e) of the Refugee Education Assistance Act of 1980 (PL 104-93). Cuban or Haitian
27

entrants are potentially eligible for benefits for a period of seven years from the date that their
status is granted.
These applicants normally have the following USCIS document:
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED)
1. I-94 with the words: CUBAN/HAITIAN ENTRANT UNDER 212(D) OF THE INA (Eligible for
Benefits)
G. Conditional Entrant
A conditional entrant was granted conditional entry into the U.S. before April 1, 1980, pursuant to
Section 203 (a) (7) of the INA. Conditional entrants are potentially eligible for benefits regardless of
any later change in their status.
These applicants normally have one of the following USCIS documents.
(NOT ACCEPTABLE IF DOCUMENTS ARE EXPIRED):
1. I-94 – with the words: ADMITTED AS A REFUGEE – CONDITIONAL ENTRY under Section
203(a) (7) of the INA. (Eligible for Benefits)
H. Abused or Battered Non-Citizen
Documented Non-Citizens may become qualified Non-Citizens when they have suffered abuse from
a parent or a spouse.
The Service Provider staff must inform the Abused or Battered applicant of the following:
1. Applicant must contact the USCIS to obtain a Petition for Abused Aliens
2. The abuse must have occurred in the U.S. and the abusive person must be a U.S. Citizen or
Lawful Permanent Resident
3. They must currently reside in the U.S.
4. They must provide any and all documentation verifying continuous residency in the U.S.
for the prior five years
Note: All periods of time that are not accounted for must be addressed by an applicant statement.
In order for the Non-Citizen to be eligible under this category, they must meet ALL of the following:
1. Possess appropriate USCIS status
2. Be battered or subject to extreme cruelty
28

3. Have a substantial connection between battery and the need for benefits
4. No longer residing with the batterer
I. Indefinite Detainee
Indefinite detention status pertains to Non-Citizens who have served their time for a criminal
conviction and have been given formal orders to leave the U.S. Subsequently, Indefinite Detainee
status is met when the Non-Citizen is allowed to indefinitely remain the U.S. because neither their
home country, nor any other country will accept them.
J. Military Connection
Non-Citizens who meet both of the following criteria are potentially eligible for benefits, regardless
of their date of entry:
1. They are a qualified Non-Citizen
2. They meet one of the following military service criteria:
a. An honorably discharged veteran or person on active duty
b. On active duty in the Armed Forces of the U.S.
c. A spouse of a veteran or person on active duty who meets one of the following:
i. Is legally married to the veteran or person on active duty
ii. Is legally separated from the veteran or person on active duty
iii. Is a widowed spouse of the veteran or person on active duty and has not
remarried
Note: The applicant remains eligible regardless of whether they are living together or apart; the
veteran or active duty person can be a U.S. Citizen or a Non-Citizen Legal Resident.
When verifying military service criteria, the following apply:
1. An honorably discharged veteran of the Armed Forces of the U.S. must present an original
or notarized copy of the veteran's discharge papers
2. To verify the active duty status an original or notarized copy of the applicant's current
orders or a military ID card (DD form 2 (active)) may be used
3. Only full-time Air Force, Army, Navy, Marine or Coast Guard is eligible
4. Any Reserve or National Guard duty is excluded
A spouse or single dependent child of a veteran or active duty alien must provide a document to
verify relationship along with military verification requirements.
Non-Citizen Alien Identification Cards
This section identifies alien ID cards that applicants may provide to determine whether they meet
one of the qualified non-citizen requirements to receive benefits. Documents cannot be EXPIRED.
29

Alien Identification Cards
The eligible ID cards listed in this section are as follows:
1. I-94 Arrival/Departure Record
a. POTENTIALLY ELIGIBLE depending on the following:
i. I-94 admission stamp used, section of law/class-code annotations; Applicant
must also meet a qualified Non-Citizen Legal Resident Status criteria
identified in Section II-A. NOT ELIGIBLE for benefits when the document
lacks a registration number
2. I-94 Parole Edition
a. POTENTIALLY ELIGIBLE depending on the following:
i. I-94 admission stamp used; section of law/class-code annotations; Applicant
must also meet a qualified Non-Citizen Legal Resident Status criteria
identified in Section II-A. NOT ELIGIBLE for benefits when the document
lacks a registration number.
3. I-151 Alien Registration Card
a. POTENTIALLY ELIGIBLE – The I-151 is the original green card. Many however were
printed on blue paper; several versions of this card exist.
i. Applicants must also meet qualified Non-Citizen Legal Resident Status
criteria identified in Section II-A.
4. I-551 Permanent Resident Card
5. Visa Stamps in Foreign Passports – Eligible when all of the following occur:
a. The Visa is stamped "Processed for I-551, temporary Evidence of Lawful Admission
for Permanent Residence".
b. Neither the Visa NOR the passport have expired. The passport's expiration date is
normally found on the same page as the person's photograph.
Note: Applicants, who have expired, lost or otherwise cannot locate their immigration documents
from USCIS are responsible for contacting USCIS for replacement documents.
Note: Qualified Non-Citizen Legal Residents may have documents described as eligible. Case
managers must examine documents to establish their expiration date and cannot accept expired
documents.
Affidavit That Document(s) Is/Are True
An eligible applicant must execute a sworn affidavit stating that the documentation provided as
listed on this document during the verification process is true.
30

1. Contractors who determine eligibility for these programs will be required to ensure that a
sworn affidavit is obtained in a way that does not delay the eligibility determination
process, or add cost to the process for the applicant.
2. Eligible applicants are exempt from providing an affidavit only if they are 60 years of age
or older, if they are Tribal Members or if they are disabled or have an incapacity of the
body or mind which makes them unable to supply such affirmation.
3. Any contractor classified as a non-profit charitable organization must notify Department
of Economic Security, Division of Aging and Adult Services (DES/DAAS), if "discovered
violations" will not be reported to ICE, also:
a. Contractors will establish their own process for reporting discovered violations to
the Federal Department of Immigration and Customs Enforcement (ICE) and are
advised to consult with legal counsel or ICE for further guidance.
Determining Non-citizen Status
To determine non-citizen status, complete the following:
1. Ask the applicant for their USCIS documentation. When the applicant states they do not
have documentation, do not question the participant further regarding their non-citizen
status.
2. When the document is provided, compare the document to the documents listed on
pages 4 through 10. If the document is one of the qualified non-citizen documents, the
non-citizen has a qualified status.
3. A nonqualified non-citizen, who is residing in the United States without the knowledge or
permission of USCIS, may do one of the following:
4. Voluntarily self-declare that they are residing in the U.S. illegally or
5. Provide Immigrations and Customs Enforcement (ICE) documents verifying violation of
USCIS law.
6. When either of these occurs, follow your Service Provider's process for reporting
discovered violations to the Federal Department of Immigration and Customs
Enforcement (ICE).
Non-Qualified Non-Citizens
Consider the following Non-Citizens as Non-Qualified. Documents include, but are not limited to the
following:
1. I-94 (Non-citizens with this document may have either qualified or nonqualified status.
The admission stamp annotated on the card determines the non-citizen's status.)
2. I-184 (Crewman Landing Permit)
31

3. I-185 (Nonresident Alien Canadian Border Crossing Card)
4. I-186 (Nonresident Mexican Border Crossing Card)
5. I-444 (-Mexican Border Visitor Permit)
6. I-586 (Nonresident Alien Border Crossing Card)
7. l-688A (Employment Authorization)
8. I-688 (Temporary Resident [This is the first card issued to non-citizens living in the U.S.
under the Amnesty Program of the Immigration Reform and Control Act of 1986.])
9. I-688B (Employment Authorization [This is the second card issued to non-citizens under
the Amnesty Program of the Immigration Reform and Control Act of 1986.])
10. I-689 (Fee Receipt-Non-citizens [With this card may have either qualified or nonqualified
status. The Provision of Law annotated on the card determines the non-citizen's status.])
11. I-766 (Employment Authorization)
12. DSP150 (Border Crossing Card [This card was introduced in 1997. Non-citizens with this
card may have either qualified or nonqualified status. The Provision of Law annotated on
the card determines the non-citizen's status.])
13. Student Visa (This card was introduced in 1998)
Ineligible Alien ID Cards
When an applicant provides one of the following alien ID cards they are INELIGIBLE for services and
the applicant must provide another eligible document. All these forms expired before January 24,
1990.
1. Any alien ID cards that are expired.
2. I-181a Memorandum of creation of record of lawful permanent residence
3. I-184 Alien crewman landing permit and identification card
4. I-185 Non-resident alien Canadian border crossing card
5. I-186 Non-resident alien Mexican border crossing card
6. I-444- Mexican border visitor permit
7. I-586 Non-resident alien border crossing card
32

8. I-688 Employment authorization
9. I-688A Employment authorization document
10. I-688B Employment authorization document
11. I-689 Fee receipt
12. I-766 Employment authorization document
13. Non-resident border crossing card
33

ATTACHMENT 1:
PAYMENT GUARANTEE
CONTACT INFORMATION
34

PAYMENT GUARANTEE CONTACT INFORMATION
--ALL UTILITIES--
APS: Online through the APS EAG system. Call the APS Caps Team
(602) 371-6774 for questions and assistance.
SRP: Email: SRPEAG@srpnet.com
Phone: (602) 236-3003
Fax: (602) 236-3003
SWG: Email: SCA-SWGAgencies@swgas.com
Phone: (877) 967-9427
Fax: (866) 997-9427
GLOBAL WATER: Fax: (520) 568-6367
TEP: Email: AgencyDesk@tep.com
Phone: 1-520-917-8418
Fax: 1-520-571-4026
UNISOURCE (Warm Spirit): Email: AgencyDesk@uesaz.com
Phone: 1-866-628-5721
Fax: 1-866-870-5163
REQUIRED INFORMATION: Guarantees should include the following information (see also
the Policy section on Payment Guarantee Process):
1. Account number
2. Customer name on account
3. Customer address
4. Date of guarantee and guarantee amount
5. Fund source (if possible)
6. Name of case worker requesting the guarantee
7. Name of organization requesting the guarantee
35

ATTACHMENT 2:
PROGRAM SUMMARIES
36

ACAA UTILITY ASSISTANCE
PROGRAM SUMMARY OVERVIEW
INFORMATION APPLIES TO: All fund sources subcontracted to human service agencies
through The Arizona Community Action Association (ACAA).
INCOME VERIFICATION: All sources of household income received during the past 30
days, including the date of application must be accounted for
and verified.
SERVICE PERIOD: A household may be assisted only once in a 12-month period for
each fund source, unless otherwise specified.
SUBSTITUTE SSN (if necessary): Zip code + Birthday (for example: if zip code is 85203 and b-day is
May 1, 1980 then the substitute SSN will be 852-03-0501)
ACCEPTABLE CRISIS REASONS
(if required): 1. Loss or reduction of income or public assistance
benefits or a delay in receiving public assistance
benefits.
2. Unexpected and/or unplanned expense that caused a
lack of resources.
3. A condition that endangers the health and safety of
the household.
CLIENT FILES MUST CONTAIN: 1. Intake sheet with client info and name of caseworker
2. Verification document for ID of client
3. Citizenship verification (for HEAF and URRD only)
4. Utility bill (or receipts for purchases of fuel)
5. Income verification
6. Crisis documentation (if required by fund source)
7. Client affidavit form (if utilized)
8. Statement of truth/release of info, signed by the client
9. Copy of payment guarantee request
PAYMENT GUARANTEE INFO: Guarantees should include the following information:
1. Account number
2. Customer name on account
3. Customer address
4. Date of guarantee and guarantee amount
5. Fund source (if possible)
6. Name of case worker requesting the guarantee
7. Name of organization requesting the guarantee
37

ARIZONA PUBLIC SERVICE (APS)
CRISIS BILL ASSISTANCE PROGRAM SUMMARY
CAN PAY: Current and past due charges, including reconnection fees or
establishment charges, incurred only at the client’s current
address. No credits can be given.
Cannot pay deposits.
Payments can be given to clients who are already enrolled in
the Equalizer Program, even if a credit balance is already
showing on the account. The payment amount should cover
the current and upcoming month’s charges, as well as any
outstanding debt due to missed payments.
Payments for clients enrolled in the Prepay Program should be
enough to cover outstanding debt and the next 30 days of
energy usage, based on historical payments made by the client,
taking into account upcoming weather conditions.
MAXIMUM GRANT AMOUNT: $400.00
ELIGIBILITY CRITERIA: Household income must be at or below 200% of the federal
poverty guidelines.
Client must be the customer of record at the current address on
the APS account.
Disconnected accounts are eligible for assistance, but charges
incurred at former residences are not eligible.
CITIZENSHIP REQUIREMENT: None
CRISIS: An acceptable crisis reason must be documented on the
application.
PAYMENT GUARANTEE: Online through the APS EAG system. Call the APS Caps Team
(602) 371-6774 for questions and assistance.
38

SALT RIVER PROJECT (SRP)
BILL ASSISTANCE PROGRAM SUMMARY
CAN PAY: Current and past due charges, reconnection fees, establishment
charges, deposits and balances from a previous SRP address.
Credits can be given to clients under circumstances where the
case manager determines that the funds are necessary for the
financial stability of the client. Credits must be given only to
clients whose circumstances truly warrant them. In these
situations, case notes should outline the details of the decision-
making process.
Payments can be given to clients who are already enrolled in
the Budget Billing program, even if a credit balance is already
showing on the account. The payment amount should cover
the current and upcoming month’s charges, as well as any
outstanding debt due to missed payments.
Payments for clients enrolled in the M-Power Program should
be enough to cover outstanding debt and the next 30 days of
energy usage, based on historical payments made by the client,
taking into account upcoming weather conditions.
MAXIMUM GRANT AMOUNT: $600.00
ELIGIBILITY CRITERIA: Household income must be at or below 60% of the current,
State Median Income (SMI) guidelines for Arizona. Unless the
household has 7 or more members, then switch to 150% of the
Federal Poverty Level (FPL) guidelines.
The client must be a household member, but does not have to
be the customer of record.
CITIZENSHIP REQUIREMENT: None
CRISIS: A hardship reason must be noted on the application or
somewhere in the case file. No additional documentation of
hardship is required.
PAYMENT GUARANTEE: Email: SRPEAG@srpnet.com
Phone: (602) 236-3003
FAX: (602) 914-8732
39

SOUTHWEST GAS LOW INCOME ENERGY CONSERVATON
BILL ASSISTANCE PROGRAM SUMMARY
CAN PAY: Current and past due charges, including deposits (up to 25% of
the agency’s allocated funds can be used to assist clients with
deposits).
A client may receive a credit under circumstances where the
case manager determines that the funds are necessary for the
financial stability of the client.
This may include assisting customers who have historically
disconnected their gas in the summer, only to have a
reconnection fee in the fall that they might have trouble paying.
By crediting them in the spring/summer months, this can allow
them to avoid such fees.
Credits must be given only to clients whose circumstances truly
warrant them. In these situations, case notes should outline the
details of the decision-making process.
MAXIMUM GRANT AMOUNT: $400.00
ELIGIBILITY CRITERIA: Household income must be at or below 200% of the federal
poverty guidelines.
Client must have the Southwest Gas account in their name or
apply for assistance by named proxy.
CITIZENSHIP REQUIREMENT: None
CRISIS: Not required.
PAYMENT GUARANTEE: Email: SCA-SWGAgencies@swgas.com
Phone: (877) 967-9427
Fax: (866) 997-9427
40

SOUTHWEST GAS ENERGY SHARE – BILL ASSISTANCE
PROGRAM SUMMARY
CAN PAY: Current and past due charges, including deposits, late charges,
reestablishment fees, and other related costs or fees.
A client may receive a credit under circumstances where the
case manager determines that the funds are necessary for the
financial stability of the client.
This may include assisting customers who have historically
disconnected their gas in the summer, only to have a
reconnection fee in the fall that they might have trouble paying.
Providing a credit in the spring/summer months can allow them
to avoid such fees.
Credits must be given only to clients whose circumstances truly
warrant them. In these situations, case notes should outline the
details of the decision-making process.
MAXIMUM GRANT AMOUNT: $400.00
ELIGIBILITY CRITERIA: Clients must have household income at or below 200% of the
federal poverty guidelines, OR a verified financial crisis or
unexpected financial difficulty.
Clients are eligible to receive assistance at different points in
time within the same 12-month period, provided that the total
assistance does not exceed the maximum grant amount ($400).
Client must be the customer of record or a household member.
CITIZENSHIP REQUIREMENT: None
CRISIS: Not required for clients whose household income is at or below
200% of the federal poverty guidelines. Clients whose
household income is above 200% of the federal poverty
guidelines may be assisted if they are experiencing a verified
financial crisis. This crisis must be documented on the
application.
PAYMENT GUARANTEE: Email: SCA-SWGAgencies@swgas.com
Phone: (877) 967-9427
Fax: (866) 997-9427
41

SOUTHWEST GAS ENERGY SHARE – REPAIR/REPLACEMENT
PROGRAM SUMMARY
CAN PAY: Costs associated with repairing natural gas equipment (or
replacement costs in cases where repair is impossible or repair
costs would exceed replacement costs).
Costs associated with gas line repair or relocation in conjunction
with the Southwest Gas Customer-Owned Yard Line (COYL)
Program.
MAXIMUM GRANT AMOUNT: $2,000.00
ELIGIBILITY CRITERIA: Clients must have household income at or below 200% of the
federal poverty guidelines, OR a condition that endangers the
health and safety of the household.
Clients may be assisted more than once in a 12-month period as
long as the cumulative total assistance during the 12-month
period does not exceed the maximum grant amount (funds can
only be used once in conjunction with the COYL program).
Client must be the customer of record or a household member.
For appliance repair/replacement: Proof of ownership of the
appliance.
For gas line repair/replacement in conjunction with COYL
program: Proof of client participation in COYL program
(completed Southwest Gas Meter Relocation Agreement, signed
by client and Southwest Gas representative).
CITIZENSHIP REQUIREMENT: None
CRISIS: Not required for clients whose household income is at or below
200% of the federal poverty guidelines. Clients whose
household income is above 200% of the federal poverty
guidelines may be assisted if they are experiencing a condition
that endangers the health and safety of household members.
This condition must be documented on the application.
ADDITIONAL DOCUMENTS For appliance repair/replacement: (1) Invoice for total costs
REQUIRED FOR CLIENT FILE: from pre-approved contractor; (2) Client statement indicating
that repairs/replacements have been completed.
For gas line repair/replacement in conjunction with COYL
program: Completed Meter Relocation Agreement, signed by
client and Southwest Gas representative.
42

Instructions for Assisting Clients in the Southwest Gas
Customer-Owned Yard Line (COYL) Program
Using Southwest Gas Energy Share – Repair/Replacement Funds
The COYL program is operated by Southwest Gas and is a service provided to certain Southwest Gas
customers who elect to allow their gas meters to be relocated at the expense of Southwest Gas.
Southwest Gas Customers who are participating in the COYL program may be eligible for additional
assistance with Southwest Gas Energy Share – Repair/Replacement funds under the following
circumstances:
1. A gas leak at the customer’s residence was discovered during the meter relocation process
AND/OR
2. The meter cannot be relocated to the original residence entry point and requires additional
plumbing to complete the installation.
In these cases, the client would incur additional costs, not covered by the COYL program. These clients
can be assisted with Southwest Gas Energy Share – Repair/Replacement funds if otherwise eligible. In
order to assist these clients, their participation in the COYL program must be verified using a copy of
their completed Meter Relocation Agreement, signed by both the client and a Southwest Gas
representative.
43

HOME ENERGY ASSISTANCE FUND (HEAF)
PROGRAM SUMMARY
The Home Energy Assistance Fund (HEAF) provides funds, which can be utilized to assist clients with
utility costs as a supplement to existing fund sources or when other fund sources are unavailable. In
addition, this fund source may be utilized to assist clients in obtaining fuel from alternative sources,
including propane, oil, wood, coal, and pellets. It may also be used to provide assistance to clients
whose utility costs are included in rental payments.
CAN PAY: Utility bills, including current and past-due charges, deposits,
late fees, service establishment and reconnection fees.
Credits may not be issued to clients, except for those already
enrolled in utility prepay programs.
Alternative fuel sources including propane, oil, wood, coal and
pellets. Agencies should create a well-defied process for
assisting clients with these fuel sources.
Utility costs included in a client’s rental agreement and
collected along with rental payments are eligible for assistance.
MAXIMUM GRANT AMOUNT: $500.00
Total grant amount for clients enrolled in a utility prepay
program should be based on historical payments made by the
client, taking into account seasonal weather conditions.
ELIGIBILITY CRITERIA: Household income must be at or below 200% of the federal
poverty guidelines.
CRISIS: An acceptable crisis reason must be documented on the
application.
CITIZENSHIP REQUIREMENT: Primary applicant must be U.S. citizen or legal resident
ADDITIONAL DOCUMENTS: Citizenship/Legal Resident status verification for primary
applicant
Invoice or receipt of purchase for alternative fuel costs
(propane, wood, pellets, etc.)
Copy of the rental agreement or a note from the landlord for
utility costs included in rent
PAYMENT GUARANTEE: See Payment Guarantee Contact Information
44

UTILITY REPAIR REPLACEMENT AND DEPOSIT (URRD)
PROGRAM SUMMARY
The Utility Repair, Replacement and Deposit (URRD) fund was established by state law (A.R.S.
§46-731) to provide assistance to low income individuals in crisis situations with deposits for
utility services and to make needed repairs and/or replacements to existing utility related
appliances or systems. In January 2007, A.R.S. §46-731 was revised to require abandoned
deposits to be administered by a qualified fuel fund entity.
CAN PAY: Deposits for utility services (electric, gas, water, telephone)
Repairs to existing utility related appliances or systems
Replacement of existing utility related appliances only in cases
where repair costs would exceed replacement costs or when an
appliance is found to be inoperable with repairs. Replacement
appliances must have an Energy Efficient Star Rating.
Guidelines for Repair/Replacement
Ownership:
The applicant must be the owner of the appliance or system to be repaired and/or replaced.
The following documents can be used to verify ownership:
1. Purchase receipt provided by the client, or
2. Statement of ownership, signed by the client
A qualified individual of the agency, vendor, or trained weatherization contractor may complete
inspection of the needed repair and/or replacement.
Appliances and Systems:
Ineligible Appliances &
Eligible Appliances & Systems
Systems
Water Heaters Televisions
Cooking Stoves Radios
Microwaves VCRs
Furnaces Hair Dryers
Air Conditioners Blenders
Home Telephone (Landlines Only) Cable TV
Evaporative Coolers Satellite Receivers
Refrigerators Water Softeners
Washers/Dryers Water Pump
Water Tanks
Pressure Tanks
45

For any appliance repair and/or replacement not listed on the list of eligible appliances, please
contact ACAA at (602) 604-0640.
MAXIMUM GRANT AMOUNT: $3,000.00
ELIGIBILITY CRITERIA: Household income must be at or below 200% of the federal
poverty guidelines.
For appliance repair/replacement: The applicant must be the
owner of the appliance or system to be repaired and/or
replaced.
A qualified individual of the agency may conduct inspection of
the needed repair and/or replacement.
CRISIS: An acceptable crisis reason must be documented on the
application.
CITIZENSHIP REQUIREMENT: Primary applicant must be a U.S. citizen or legal resident.
ADDITIONAL DOCUMENTS: Citizenship/Legal Resident status verification for primary
applicant
For appliance repair/replacement: (1) Proof of ownership of
appliance or system (receipt or client statement is acceptable);
(2) Invoice for total costs from pre-approved contractor; (3)
Client statement indicating that repairs/replacements have
been completed and are satisfactory.
PAYMENT GUARANTEE: See Payment Guarantee Contact Information
PAYMENT FOR REPAIR/REPLACEMENT: After completion of work, inspection, written confirmation from
client that work was completed and is satisfactory, and receipt
of appropriate documentation, such as an invoice.
46

TUCSON ELECTRIC POWER (TEP) BILL ASSISTANCE
PROGRAM SUMMARY
CAN PAY: Current and past due charges.
Can pay deposits, reconnect fees and establishment charges.
No credits can be given on any accounts.
MAXIMUM GRANT AMOUNT: $400.00
ELIGIBILITY CRITERIA: Household income must be at or below 150% of the federal
poverty guidelines.
The client must be the customer of record, and/or income
eligible household member
CITIZENSHIP REQUIREMENT: None
CRISIS: An acceptable crisis reason must be documented on the
application.
PAYMENT GUARANTEE: Email: AgencyDesk@tep.com
Phone: 1-520-917-8418
Fax: 1-520-571-4026
47

WARM SPIRIT FUND PROGRAM SUMMARY
(Funds Provided by UniSource Energy)
CAN PAY: Utility bills, including current and past due charges, deposits,
late fees, service establishment and reconnection fees.
No credits can be given on any accounts.
MAXIMUM GRANT AMOUNT: $500.00
ELIGIBILITY CRITERIA: Household income must be at or below 200% of the federal
poverty guidelines.
Applicant must be customer of record, and/or income eligible
household member.
CITIZENSHIP REQUIREMENT: None
CRISIS: An acceptable crisis reason must be documented on the
application.
PAYMENT GUARANTEE: Email: AgencyDesk@uesaz.com
Phone: 1-866-628-5721
Fax: 1-866-870-5163
48

UNISOURCE ELECTRIC BILL ASSISTANCE
PROGRAM SUMMARY
CAN PAY: Current and past due charges.
Can pay deposits, reconnect fees and establishment charges.
No credits can be given on any accounts.
MAXIMUM GRANT AMOUNT: $400.00
ELIGIBILITY CRITERIA: Household income must be at or below 150% of the federal
poverty guidelines.
The client must be the customer of record, and/or income
eligible household member
CITIZENSHIP REQUIREMENT: None
CRISIS: An acceptable crisis reason must be documented on the
application.
PAYMENT GUARANTEE: Email: AgencyDesk@uesaz.com
Phone: 1-866-628-5721
Fax: 1-866-870-5163
49

GLOBAL WATER LOW INCOME RELIEF TARIFF
PROGRAM SUMMARY
WATER COMPANIES: Santa Cruz Water Company (Water – Maricopa)
Palo Verde Utilities Company (Sewer – Maricopa)
Water Utility of Greater Tonopah
Water Utility of Northern Scottsdale
Willow Valley Water Company
CAN PAY: Current and past due charges, deposits, late fees, reconnection
fees, service fees, returned payment fees, after hours service
fees (where applicable).
MAXIMUM GRANT AMOUNT: $250.00
ELIGIBILITY CRITERIA: Household income must be at or below 200% of the federal
poverty guidelines.
Clients must not have a history of meter tampering or cutting
locks.
CITIZENSHIP REQUIREMENT: None.
CRISIS: An acceptable crisis reason must be documented on the
application.
PAYMENT GUARANTEE: Fax: (520) 568-6367
50