How to Complete and Submit the Arizona DES FAA-0053A Employment Verification Form

The Arizona DES FAA-0053A form is an employment verification form the Department of Economic Security uses to confirm an applicant’s wages and work status when deciding eligibility for SNAP, TANF, or AHCCCS benefits. Your employer fills it out. You submit it to DES through the Health-e-Arizona Plus portal, by fax, or by mail. Getting the form back from your employer quickly and completely is usually the slowest part of an Arizona benefits application, so it helps to know exactly what it asks and how to move it through the system.

Where to Get the Form

The form is a fillable PDF on the Arizona DES digital library, listed as “Verification of New/Current Employment.”¹ You can download it and email the blank PDF straight to your employer so they can type into it, or print it and hand it over. A caseworker may also give you a copy during an interview, and local DES offices stock paper copies.

What Your Employer Will Fill Out

The form has three main sections, plus a top block for identification. The person completing it needs access to payroll records, so route it to a payroll manager, HR representative, or bookkeeper rather than a direct supervisor who may not have the numbers.

Identification Block

At the top, the form asks for the employee’s full legal name and Social Security number, then the preparer’s printed name, title, company name, phone, fax, and date.² It does not ask for the employer’s street address.

Section A: Employment and Pay

This is the longest section. Your employer provides:

Hire date and date of first paycheck
Rate of pay and anticipated gross income
Weekly and daily hours, including a range if hours vary
Days of the week worked
Pay frequency (daily, weekly, biweekly, twice monthly, or monthly) and the pay period start and end dates
Overtime rate, typical overtime hours, and whether overtime will continue
Tips, bonuses, commissions, and shift pay, with a range of amounts
Reimbursements for travel, lodging, or uniforms

Section A also asks whether pay is direct-deposited, whether child support is withheld, whether income changes are coming, whether the employee is on a leave of absence or receiving short- or long-term disability, whether wages come through the Workforce Investment Act program, and whether there is a pending or active workers’ compensation claim.²

Section B: Health Insurance

Section B asks whether the employer offers health insurance, whether the employee has coverage or has declined it, and, where coverage exists, the insurance company name and address, policy number, coverage dates, and insured dependents with their relationships.² DES uses this for AHCCCS screening alongside SNAP and TANF.

Section C: Paychecks Issued

Section C is a table listing every paycheck issued over a specified date range. Each row needs the month and year, pay period ending date, the date the check was paid, gross earnings, hours worked, and tips.² This is where caseworkers calculate average monthly income. A missing pay period or a blank hours column almost always triggers a follow-up request.

Getting It Back Without Delays

A few practical steps help:

Email the PDF so your employer can complete it electronically. A typed signature counts as a valid signature.²
Send it to someone with payroll access, not just your direct supervisor.
Before submitting, confirm every pay period in Section C has a row filled, with real numbers in the gross earnings, hours, and tips columns rather than “varies.”
Check that every yes/no box is marked. Blank checkboxes read like skipped questions and prompt caseworkers to request a new form.

How to Submit the Completed Form

Once it’s signed and dated, you have three ways to get it to DES. The online option is fastest and creates a timestamped record.

Health-e-Arizona Plus Upload

Go to healthearizonaplus.gov. You don’t need to log in. Verify your identity using your name, date of birth, and either the last four digits of your Social Security number, your AHCCCS ID, or your application ID. You’ll see a list of outstanding verification factors. Click “Upload” next to income verification, choose your file, and submit. The portal accepts JPG, PNG, PDF, and TIFF files up to 6 MB. Password-protected documents won’t go through.³

Fax

Fax the form to one of two numbers:

(602) 257-7031 for area codes 602, 480, and 623
(844) 680-9840 toll-free from any other area code

Keep the confirmation page as proof of delivery.⁴

Mail

Mail to:

Arizona Department of Economic Security
PO Box 19009
Phoenix, AZ 85005-9009⁴

Use a tracked mailing method. Mail is the slowest route, and applications close to the processing deadline can’t absorb the extra transit time.

If Your Employer Won’t Fill It Out

Tell your caseworker right away. Under Arizona Revised Statutes § 46-203, DES has authority to investigate benefit applications and request information from outside parties, including employers, so cooperation has a statutory basis. DES policy also accepts other forms of income verification, including pay stubs and data from third-party payroll services like Equifax (The Work Number), Experian Verify, Thomas & Company, and Verify Advantage.⁵ Ask whether one of these can substitute while you continue working on the form.

What Happens After You Submit

Caseworkers pull the Section C wage data to calculate your monthly income and benefit amount. Federal rules give DES up to 30 calendar days from the application date to decide SNAP eligibility.⁶ If anything on the form is incomplete or unclear, DES will contact you or your employer, and the clock keeps running.

Households in severe financial hardship may qualify for expedited SNAP processing, with benefits loaded onto an EBT card within seven calendar days of the application. To qualify, gross income for the application month generally needs to be under $150 with liquid resources of $100 or less, or combined income and resources must be less than rent or mortgage plus utility costs.⁷ Expedited applicants still need to submit the FAA-0053A afterward to keep benefits going.

Penalties for False Information

The wage numbers on this form matter. Anyone found to have intentionally misstated facts to obtain SNAP benefits faces disqualification for one year on a first offense, two years on a second, and permanent disqualification on a third.⁸ Fraud involving $5,000 or more in benefits is a felony punishable by fines up to $250,000, up to 20 years in prison, or both.⁹ Employers who knowingly report false wages can be exposed to the same fraud liability. Honest arithmetic mistakes are a different matter: caseworkers cross-check reported wages against state wage databases and quarterly tax filings, and small discrepancies are usually corrected without penalty.

1
Arizona Department of Economic Security. Verification of New/Current Employment
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Arizona Department of Economic Security. Arizona DES FAA-0053A Verification of New/Current Employment
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Health-e-Arizona Plus. Uploading Documents to Health-e-Arizona Plus
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Arizona Department of Economic Security. 127 FAA Mailing Address and Fax Number
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Arizona Department of Economic Security. Providing Verification
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eCFR. 7 CFR 273.2 Office Operations and Application Processing
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Arizona Department of Economic Security. Requirements for NA Expedited Services (NAX)
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Office of the Law Revision Counsel. 7 U.S. Code 2015 – Eligibility Disqualifications
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Office of the Law Revision Counsel. 7 USC 2024 – Unauthorized Use, Transfer, Acquisition, Alteration, or Possession of Benefits