INSTRUCTIONS: ARIZONA UNPAID COPAYMENT WORKSHEET (Form CCA-1021A)

When an insurance company is unsuccessful in obtaining co-payment from the parent of a child which has received treatment in Arizona, they may file a form notifying the child care specialist. This document CCA-1021A can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 1: In the first blank box, enter the name of the child care specialist who provided treatment.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 2: In the second blank box, enter the fax number of the child care specialist, including the area code.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 3: In the third blank box, enter the provider's name.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 4: In the fourth blank box, enter the provider's policy number.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 5: In the fifth blank box, enter the name of a provider contact person.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 6: In the sixth blank box, enter a provider contact phone number, including the area code.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 7: In the seventh blank box, enter the name of the parent or person responsible for the child.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 8: In the eighth blank box, enter the parent or responsible person's ID number.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 9: In the ninth blank box, enter the names of all children concerned.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 10: On the first blank line, enter the beginning date of the time period for which payment is being sought.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 11: On the second blank line, enter the ending date of the time period for which payment is being sought.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 12: On the third blank line, enter the total additional charges owed.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 13: On the fourth blank line, enter the balance of the outstanding copayment owed.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 14: Indicate with a check mark whether attempts have been made to obtain the outstanding copayment orally, in written form, through small claims court, or through other means. If the latter, specify.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 15: The contact person should sign and date the form.

INSTRUCTIONS: ARIZONA CERTIFICATION FOR DIRECT SERVICE POSITION (Form ACY-1287A)

If you apply for a position with the Arizona Department of Economic Security providing direct service to children or vulnerable individuals, you will be required to complete a form ACY-1287A. This document can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Certification For Direct Service Position ACY-1287A Step 1: In the first blank box, enter your last name, first name and middle initial.

Arizona Certification For Direct Service Position ACY-1287A Step 2: In the second blank box, enter your Social Security number.

Arizona Certification For Direct Service Position ACY-1287A Step 3: In the third blank box, enter any aliases, such as your maiden name or nicknames.

Arizona Certification For Direct Service Position ACY-1287A Step 4: In the fourth blank box, enter your date of birth.

Arizona Certification For Direct Service Position ACY-1287A Step 5: In the fifth blank box, enter your street address, city, state and zip code.

Arizona Certification For Direct Service Position ACY-1287A Step 6: Indicate with a check mark whether or not you are currently the subject of a child abuse investigation in Arizona or any other state or jurisdiction.

Arizona Certification For Direct Service Position ACY-1287A Step 7: Indicate with a check mark whether you have ever been the subject of a child abuse investigation in Arizona or any other state or jurisdiction.

Arizona Certification For Direct Service Position ACY-1287A Step 8: If you answered "yes" in response to Step 7, write what the allegations were in the blank space where indicated.

Arizona Certification For Direct Service Position ACY-1287A Step 9: If you answered "yes" in response to Step 7, write when the investigation was conducted in the blank space where indicated.

Arizona Certification For Direct Service Position ACY-1287A Step 10: If you answered "yes" in response to Step 7, write where the investigation was conducted in the blank space where indicated.

Arizona Certification For Direct Service Position ACY-1287A Step 11: If you wish to provide additional information concerning past investigations of child abuse allegations, you may provide a written explanation on the second page. Do not include the names of any children or persons involved in the investigation.

Arizona Certification For Direct Service Position ACY-1287A Step 12: Sign and date the bottom of the first page.

INSTRUCTIONS: ARIZONA ELECTRONIC PAYMENT AUTHORIZATION (Form CSE-1129A)

To authorize the Arizona State Disbursement Unit to supervise payment of child or spousal support through electronic direct deposit, a form CSE-1129A should be completed by the person making payment. This document can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Electronic Payment Authorization CSE-1129A Step 1: Check the first box if filing a new direct deposit authorization.

Arizona Electronic Payment Authorization CSE-1129A Step 2: Check the second box if filing for a new electronic payment card.

Arizona Electronic Payment Authorization CSE-1129A Step 3: Check the third box if filing to stop EPC and start direct deposits.

Arizona Electronic Payment Authorization CSE-1129A Step 4: Check the fourth box if filing to stop direct deposits and start EPC.

Arizona Electronic Payment Authorization CSE-1129A Step 5: Check the fifth box if you are filing this form only to make changes to bank account information already on file.

Arizona Electronic Payment Authorization CSE-1129A Step 6: If you receive or have received cash assistance in the past, and/or have applied for IV-D assistance, or if you have received assistance from the Department of Child Support Enforcement, check the box next to "IV-D" and enter your ATLAS case number.

Arizona Electronic Payment Authorization CSE-1129A Step 7: If none of the statements in Step 6 apply and your case only involves a local court, check the box next to "Non IV-D Case."

Arizona Electronic Payment Authorization CSE-1129A Step 8: Enter the custodial parent's name in the first blank box and your contact phone number in the second blank box.

Arizona Electronic Payment Authorization CSE-1129A Step 9: Enter the custodial parent's date of birth in the third blank box and their Social Security number in the fourth blank box.

Arizona Electronic Payment Authorization CSE-1129A Step 10: Enter the custodial parent's current address in the fifth blank box.

Arizona Electronic Payment Authorization CSE-1129A Step 11: Indicate with a check mark whether filing regarding a checking or savings account.

Arizona Electronic Payment Authorization CSE-1129A Step 12: Give your ABA bank routing number or account number, your financial institution's name, and one or both names (as applicable) on the account.

Arizona Electronic Payment Authorization CSE-1129A Step 13: Print and sign your name and enter the date at the bottom of the form.

  INSTRUCTIONS: ARIZONA DCSE MODIFICATION PACKET (Form CSE-1178A)

Arizona recipients or payers of child support who have experienced a significant change in their financial situation may use a packet CSE-1178A to request a change in support payments. This packet can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona DCSE Modification Packet CSE-1178A Step 1: The first two pages contain instructions for completing and using this packet.

Arizona DCSE Modification Packet CSE-1178A Step 2: The third page contains a request for modification review, which must be submitted as part of your application. This document requires you to provide your name, current address, home, cell and work phone numbers, and the other party's address and phone number, as well as your date of last contact with them.

Arizona DCSE Modification Packet CSE-1178A Step 3: The fourth page contains a request for modification. Here, you must indicate your reason for seeking a modification in payments using a check mark next to the appropriate statement.

Arizona DCSE Modification Packet CSE-1178A Step 4: The fifth page contains an agreement to accept service by mail of 10 different documents that may be involved in the process.

Arizona DCSE Modification Packet CSE-1178A Step 5: The rest of the form contains an Affidavit of Financial Information. The first page of this document requires you to provide your name and contact information.

Arizona DCSE Modification Packet CSE-1178A Step 6: Sign and date your name at the top of the second page and read the instructions.

Arizona DCSE Modification Packet CSE-1178A Step 7: Section 1 on the third page concerns general information.

Arizona DCSE Modification Packet CSE-1178A Step 8: Section 2 on the fourth page concerns your employment, while Section 3 concerns your education and training.

Arizona DCSE Modification Packet CSE-1178A Step 9: Section 4 on the fifth page concerns your gross monthly income.

Arizona DCSE Modification Packet CSE-1178A Step 10: Section 5 on the sixth page concerns self-employment income, if applicable. Section 6 on this page should only be completed by the unemployed or self-employed.

Arizona DCSE Modification Packet CSE-1178A Step 11: Section 7 begins on the seventh page and is a schedule of all monthly expenses and continues through the ninth page.

Arizona DCSE Modification Packet CSE-1178A Step 12: Section 8 on the ninth page concerns your parenting or visitation time.

INSTRUCTIONS: ARKANSAS PATERNITY ACKNOWLEDGMENT SUPPLY ORDER FORM

For a hospital to obtain forms from the Paternity Acknowledgment Program operated by the Child Support Enforcement department of the Arkansas Department of Finance and Administration, use the document discussed in this form. This document can be obtained from the website operated by the Arkansas Department of Finance and Administration.

Arkansas Paternity Acknowledgment Supply Order Form Step 1: On the first blank line, enter the date.

Arkansas Paternity Acknowledgment Supply Order Form Step 2: On the second blank line, enter your name.

Arkansas Paternity Acknowledgment Supply Order Form Step 3: On the third blank line, enter the name of the hospital where birth was given.

Arkansas Paternity Acknowledgment Supply Order Form Step 4: On the fourth blank line, enter the hospital's street address.

Arkansas Paternity Acknowledgment Supply Order Form Step 5: On the fifth blank line, enter the hospital's city, state and zip code.

Arkansas Paternity Acknowledgment Supply Order Form Step 6: On the sixth blank line, enter the hospital's phone number.

Arkansas Paternity Acknowledgment Supply Order Form Step 7: On the seventh blank line, enter the hospital's fax number.

Arkansas Paternity Acknowledgment Supply Order Form Step 8: On the eighth blank line, enter the hospital's email address.

Arkansas Paternity Acknowledgment Supply Order Form Step 9: If requesting paternity acknowledgment brochures in English, enter the quantity needed on the ninth blank line.

Arkansas Paternity Acknowledgment Supply Order Form Step 10: If requesting paternity acknowledgment brochures in Spanish, enter the quantity needed on the tenth blank line.

Arkansas Paternity Acknowledgment Supply Order Form Step 11: If requesting paternity affidavits in English, enter the quantity needed on the tenth blank line.

Arkansas Paternity Acknowledgment Supply Order Form Step 12: In requesting paternity affidavits Spanish translation flyers, enter the quantity needed on the eleventh blank line.

Arkansas Paternity Acknowledgment Supply Order Form Step 13: If requesting a video in English, enter the quantity needed on the twelfth blank line.

Arkansas Paternity Acknowledgment Supply Order Form Step 14: If requesting a video in Spanish, enter the quantity needed on the thirteenth blank line.

Arkansas Paternity Acknowledgment Supply Order Form Step 15: If requesting a staff training video, enter the quantity needed on the fourteenth blank line.

Arkansas Paternity Acknowledgment Supply Order Form Step 16: Enter any miscellaneous comments where indicated.