Form CCA-1141A FORNA "Direct Deposit Enrollment - DES Certified Homes/Relative Providers" - Arizona

What Is Form CCA-1141A FORNA?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CCA-1141A FORNA by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form CCA-1141A FORNA "Direct Deposit Enrollment - DES Certified Homes/Relative Providers" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1141A FORNA (05-18)
Page 1 of 1
Child Care Administration
DIRECT DEPOSIT ENROLLMENT
DES CERTIFIED HOMES/RELATIVE PROVIDERS
Initial Request
Change Request
Provider’s Name (Last, First, M.I.)
Provider ID NO.
Provider’s Home Address (No., Street)
City
State
ZIP Code
Provider’s Mailing Address (If different) (No., Street)
City
State
ZIP Code
Daytime Phone Number
Name of Financial Institution
Rounting NO.
Account NO.
I authorize the State of Arizona and the financial institution to process credit entries to the bank account number stated on
this form. I will notify the State of Arizona of any known changes or closure of my bank account. When the State of Arizona
is notified by my financial institution of changes affecting this direct deposit, the State of Arizona is authorized to make the
applicable changes. This authorization is to remain in effect until a new authorization is received.
Signature
Date
Please submit this form with a copy of a voided check to:
Department of Economic Security
Child Care Administration
Payment Processing Unit
P.O. Box 6123, 5472
Phoenix, AZ 85005
NOTE:
Your enrollment cannot be processed without a copy of a voided check attached. Please allow 60 days for Direct
Deposit to start. Thank you.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
Disponible en español en línea o en la oficina local.
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1141A FORNA (05-18)
Page 1 of 1
Child Care Administration
DIRECT DEPOSIT ENROLLMENT
DES CERTIFIED HOMES/RELATIVE PROVIDERS
Initial Request
Change Request
Provider’s Name (Last, First, M.I.)
Provider ID NO.
Provider’s Home Address (No., Street)
City
State
ZIP Code
Provider’s Mailing Address (If different) (No., Street)
City
State
ZIP Code
Daytime Phone Number
Name of Financial Institution
Rounting NO.
Account NO.
I authorize the State of Arizona and the financial institution to process credit entries to the bank account number stated on
this form. I will notify the State of Arizona of any known changes or closure of my bank account. When the State of Arizona
is notified by my financial institution of changes affecting this direct deposit, the State of Arizona is authorized to make the
applicable changes. This authorization is to remain in effect until a new authorization is received.
Signature
Date
Please submit this form with a copy of a voided check to:
Department of Economic Security
Child Care Administration
Payment Processing Unit
P.O. Box 6123, 5472
Phoenix, AZ 85005
NOTE:
Your enrollment cannot be processed without a copy of a voided check attached. Please allow 60 days for Direct
Deposit to start. Thank you.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
Disponible en español en línea o en la oficina local.