Screening for Family Caregiver Reimbursement Program
This program is offered through the Arizona Department of Economic Security. When you submit this form to the Arizona Caregiver Coalition, we will let you know if you meet requirements and are eligible to submit an application.
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
What is your relationship to the person you care for?
spouse / domestic partner
son / daughter (in law)
sibling (brother, sister, step/adoptive)
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 a family caregiver?
Is this the first time you are applying?
Is your family member 18 years or older?
Are you and your family member Arizona residents?
Does your family member require assistance with one or more activities of daily living (toileting, bathing, dressing, grooming, eating, mobility, or transferring)?
Does your income meet these income criteria?
Your income and your family member's income must be $75,000 or less in total income
As a couple, you must earn less than $150,000 per year in total income including the family member's income)
Your project or purchase
Still planning to do it
Did or will the home modification or purchase of assistive technology occur on or after January 1, 2020?
Do you have receipts for the home modification or assistive care technology dated on or after January 1, 2020?
Did you modify or make changes to your home or purchase assistive technology for your family member?
Preferred communication by:
For office use; leave blank (action)
Sent application by mail
Sent application with link by e-mail
Need to follow-up
For office use; leave blank
CR under 18
There is no caregiver
Can't afford to pay
Income too high
Should be Empty: