Overview
Note: This program is not a financial assistance program.
Goal
Process to qualify and apply
- Complete the pre-screening form above, or contact the Caregiver Resource Line at (888) 737-7494 to complete the pre-screening questions with a Caregiver Resource Specialist.
- If the caregiver passes the pre-screening, the Caregiver Resource Specialist will mail or email a copy of the application, Medical Need Verification Form and W-9 (to receive a reimbursement check, if approved).
- The family caregiver will need to complete and submit the application and required documents below.
- Once all documents are submitted to the Caregiver Coalition, they will be reviewed, and the family caregiver will be contacted on next steps within 90 days.
Important
Qualifying Expenses
- Improving or altering the family caregivers’ residence whether it be owned or rented.
- Purchasing/leasing equipment or assistive care technology for the family member to enable/assist/carry out one or more activities of daily living such as toileting, bathing, dressing, grooming, eating, mobility, or transferring.
Examples of qualifying expenses are not limited to this list and include:
Home Modification Costs
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Assistive Care Technology
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Expenses NOT Allowable
- Regular food, clothing, transportation expenses or gifts provided to family member.
- Ordinary household maintenance or repair that is not directly related to and necessary for the care of the family member.
- Any amount that is paid for or reimbursed by the federal government or state of Arizona.
- Reimbursement does not include covered expenses from the family member’s insurance policy.
Go to: Frequently Asked Questions (FAQ)
Documents Needed to Apply
(click for printer-friendly PDF)
Family Caregiver |
Required | Copy of one (1) |
Proof of gross income for family caregiver and qualified family member’s income combined
Earn $75,000/year or less in gross income (Caregiver + Qualified Family Member = gross income) or As a couple, earn less than $150,000/year in gross income (caregiver + spouse + qualified family member = gross income) |
Pay stub Income taxes Veteran Award Letter Social Security Income (SSI) award Any public benefit award letter (TANF, SNAP, etc.) |
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Proof of Age 18 years or older |
Arizona driver’s license ID card (with birthdate) Birth certificate |
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Proof of Arizona Residency |
Arizona driver’s license Utility bill |
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W-9 (provided) |
W-9 (completed)
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Proof of construction costs/ purchase or lease of assistive care technology |
Receipt (s) | |
Qualified Family Member |
Required | Signed copy |
Proof of Gross Income for Family Caregiver and Qualified Family Member’s Income Combined Earn $75,000/year or less in gross income (Caregiver + Qualified Family Member = gross income) or As a couple, earn less than $150,000/year in gross income (caregiver + spouse + qualified family member = gross income) |
Pay stub Income taxes Veteran Award Letter Social Security Income (SSI) award Any public benefit award letter (TANF, SNAP, etc.) |
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Proof of Medical Need Assistance from the family caregiver with one or more activities of daily living, (ADL) (toileting, bathing, dressing, grooming, eating, mobility, or transferring) |
Medical Need Verification Form (provided, click on form to download) | |
Proof of Age 18 years or older |
Arizona driver’s license ID card (with birthdate) Birth certificate |