2023 Arizona Family Caregiver Reimbursement Program Checklist
This program is offered through the Arizona Department of Economic Security. When you submit this form to the Arizona Caregiver Coalition, we will send you an application and related information. The following questions and checklist will provide guidelines for the application process, however, is NOT meant as a disqualifier.
Street Address Line 2
State / Province
Postal / Zip Code
Language other than English?
What is your status
Family Caregiver, caring for a family member
Person over 60 (not a caregiver, but perhaps you have a caregiver)
Agency / Professional
How did you hear about us?
Media, news, radio
Please answer all these screening questions.
If you answer "no" to any questions or are not sure, you may still submit the form, but you may not be eligible at this time.
You (caregiver) and your family member
Are you and your family member Arizona residents?
Do you file joint federal and/or state income tax returns?
Do you file single or married person filing separately on your federal and/or state income tax returns?
Have you applied for the FCRP?
Have you received up to $1,000 reimbursement since 2020?
Is your qualifying family member at least 18 years of age during the calendar year?
Does your qualifying family member require assistance with one or more activities of daily living (toileting, bathing, dressing, walking, eating or transferring)?
How are you related to the qualifying family member(s)? The relationship may be of the whole, half blood or by adoption.
Child or Spouse's Child
Qualifying Expenses (Your project or purchase)
Did you provide care to or support to the qualifying family member in your home or in their home?
Did you incur expenses related to the care you provide in the calendar year of the application?
Were improvements or alterations made in the family caregiver's (you) or the qualifying member's residence to assist with care and support?
Do you have receipts or copies of receipts to submit with your application? Reminder: unpaid invoices or invoices that do not show a balance paid will not be processed.
Preferred communication by:
For office use; Do NOT fill out, please leave blank (action)
Sent application by mail
Sent application with link by e-mail
Need to follow-up
Should be Empty: