Supporting Documentation | ACC Lifespan Respite Programs

Documentation Required by Program

Form Type	Partners	Care Voucher $599	Care Voucher $2,400
Identification (for both Caregiver & Care Recipient)	Yes	Yes	Yes
Medical Needs Form	Yes	Yes	Yes
W-9 Form for Caregiver	No	No	Yes

How to Submit Documentation:

Attach/upload - Upload a photo or scanned copy below. Accepted formats: JPG, PNG, PDF.
Email: info@azcaregiver.org
Mail: Arizona Caregiver Coalition, PO Box 21623, Phoenix, AZ 85036

END
Caregiver Name

First NameLast Name
Which program(s) are you applying for?

Care/Voucher ProgramPartners ProgramUnsure
Identification (Caregiver and Care Recipient)

Please upload: Caregiver and Care Recipient Identification + address verification (if applicable) | required for all programs
Cancelof
Medical Needs Form

Please upload: Medical Needs Form | required for all programs
Cancelof
Caregiver W-9 (if applicable)

Please upload: W-9 (if applicable) | required for Care Voucher $2,400
Cancelof
Documentation of Financial Hardship (if applicable)

Please upload: Documentation of Financial Hardship (if applicable) | required for Care Voucher $2,400
Cancelof
Should be Empty:

Lifespan Respite Program Application