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.