INSTRUCTIONS: ARIZONA CERTIFICATION STATEMENT FOR PROVIDING CHILD CARE SERVICES (Form CC-201)

Those applying for a position in Arizona to provide child care services are required to submit to a background check concerning their suitability to have unsupervised access to vulnerable persons. Form CC-201 is an affidavit completed by the applicant as part of a background check process that also includes having their fingerprints taken, which will be reviewed by the Arizona Department of Public Safety and the Federal Bureau of investigation. This document can be obtained from the website maintained by the Arizona Department of Economic Security. Make sure you submit the most current version of this form, as previous versions will not be accepted. Failure to submit full and accurate information may be grounds for prosecution.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 1: Enter your first, middle and last name in the first blank box.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 2: Enter your date of birth in the second blank box.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 3: Enter your street address, apartment number (if applicable), city, state and zip code in the third blank box.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 4: Indicate with a check mark whether or not you have been convicted of or are under pending investigation for any prior crimes. If you have, provides the dates, location or jurisdiction, circumstances and outcome.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 5: Answer the next four questions by checking "yes' or "no" as appropriate.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 6: The second page concerns non-appealable offenses. Check "yes" or "no" in response to all non-appealable offences listed.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 7: The third page concerns offenses appealable five years after conviction. Check "yes" or "no" in response to all such offences listed.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 8: The fourth and fifth pages concerns appealable offenses. Check "yes" or "no" in response to all such offenses listed.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 9: Sign and date the first page in the presence of a notary public.

INSTRUCTIONS: ARIZONA CHILD SUPPLEMENTAL PAGE (Form CS-167-A)

When filing an Arizona request for Title IV-D Child Support Services using a form CS-167, a form CS-167-A is used supplementally if you need to document more than two children from the same father. Both forms can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Child Supplemental Page CS-167-A Step 1: In the first blank box, enter the child's last name.

Arizona Child Supplemental Page CS-167-A Step 2: In the second blank box, enter the child's first and middle names.

Arizona Child Supplemental Page CS-167-A Step 3: In the third blank box, enter the child's Social Security number.

Arizona Child Supplemental Page CS-167-A Step 4: In the fourth blank box, indicate with a check mark whether or not the child lives with you.

Arizona Child Supplemental Page CS-167-A Step 5: In the fifth blank box, write your relationship to the child.

Arizona Child Supplemental Page CS-167-A Step 6: In the sixth blank box, enter the child's date of birth.

Arizona Child Supplemental Page CS-167-A Step 7: In the seventh blank box, enter the child's place of birth.

Arizona Child Supplemental Page CS-167-A Step 8: In the eighth blank box, enter the child's place of conception.

Arizona Child Supplemental Page CS-167-A Step 9: In the ninth blank box, indicate the child's gender with a check mark.

Arizona Child Supplemental Page CS-167-A Step 10: In the tenth blank box, indicate with a check mark whether the child's non-custodial parent has lived with them in Arizona.

Arizona Child Supplemental Page CS-167-A Step 11: In the eleventh blank box, indicate the child's race with a check mark.

Arizona Child Supplemental Page CS-167-A Step 12: In the twelfth blank box, indicate with a check mark whether or not the child is a member of a tribe. If yes, give their name and tribal census number.

Arizona Child Supplemental Page CS-167-A Step 13: Indicate whether the biological parents were married, divorced or never married at the time of birth with a check mark in the thirteenth blank box.

Arizona Child Supplemental Page CS-167-A Step 14: The next section concerns any man the woman was married to at the time of birth. The section after that concerns establishment of paternity. The last section concerns any court orders concerning the child.

INSTRUCTIONS: ARIZONA REQUEST TO CLOSE CHILD SUPPORT CASE (Form CSE-1160A)

In order to request that an Arizona child support case be closed, you should file a form CSE-1160A. This form is for the completion of the person receiving payment only. This document can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Request To Close Child Support Case CSE-1160A Step 1: On the first line, enter your name.

Arizona Request To Close Child Support Case CSE-1160A Step 2: On the second line, enter your phone number, including the area code. 

Arizona Request To Close Child Support Case CSE-1160A Step 3: On the third line, enter your street address, including any applicable apartment or suite number.

Arizona Request To Close Child Support Case CSE-1160A Step 4: On the fourth line, enter your city.

Arizona Request To Close Child Support Case CSE-1160A Step 5: On the fifth line, enter your state.

Arizona Request To Close Child Support Case CSE-1160A Step 6: On the sixth line, enter your zip code.

Arizona Request To Close Child Support Case CSE-1160A Step 7: On the seventh line, enter the applicable ATLAS case number.

Arizona Request To Close Child Support Case CSE-1160A Step 8: On the eighth line, enter the date on which you are completing this form.

Arizona Request To Close Child Support Case CSE-1160A Step 9: The paragraph below states that you understand the implications of your request, including the necessity of reapplying to the Department of Child Support Enforcement if you require services in the future. 

Arizona Request To Close Child Support Case CSE-1160A Step 10: The next paragraph states that you understand that no more action will be taken on your case, unless you file another application or your child receives TANF benefits.

Arizona Request To Close Child Support Case CSE-1160A Step 11: To sign and date the form, you must appear before a notary public. In the event that you need a notary but are unable to pay for one's services, your child support enforcement services office will provide a notary at no cost. Enter your signature on the first blank line and the date on the second blank line. The notary will then complete the section of the form reserved for them.

Arizona Request To Close Child Support Case CSE-1160A Step 12: Mail the form to the P.O. box listed on the form.