Form CCA-1015A FORFF "Withdrawal or Termination Request" - Arizona

What Is Form CCA-1015A FORFF?

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 July 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-1015A FORFF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

ADVERTISEMENT
ADVERTISEMENT

Download Form CCA-1015A FORFF "Withdrawal or Termination Request" - Arizona

1213 times
Rate (4.4 / 5) 73 votes
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1015A FORFF (07-18)
Child Care Administration
WITHDRAWAL OR TERMINATION REQUEST
REQUESTOR INFORMATION
Name (Last, First, M.I.)
Phone NO. (Include area code)
Address (No., Street)
City
State
ZIP Code
Client ID or Social Security Number
(Complete Sections A, B, and C)
A. I wish to withdraw or terminate:
My application for Child Care Assistance
My Child Care Assistance
My request for a fair hearing. I understand that if I received Child Care Assistance pending the outcome of a
hearing, I may be required to repay any benefits received for which I am not eligible.
B. Reason for withdrawal/termination:
Moving out of state to (State)
. Date of move (Month/Day/Year)
.
Other (explain):
C. I understand that this request will result in either the termination of my Child Care Assistance, the denial of my
application for Child Care Assistance, or the withdrawal of my request for a fair hearing.
Client’s Name (Last, First, M.I.)
Month/Day/Year
Client’s Signature
Month/Day/Year
Child Care Specialist’s Signature
Month/Day/Year
OFFICE USE ONLY
To be Completed by DES Child Care Specialist
D. Verbal withdrawal or termination request (to be completed by the Specialist along with Sections A and B when
the client’s request is received verbally).
Client’s Name (Last, First, M.I.)
Month/Day/Year
Child Care Specialist’s Signature
Month/Day/Year
Date of verbal request (Month/Day/Year)
In person
By telephone
Routing: Original – CCA, Copy – Client, Copy – Office of Appeals (if applicable)
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-1015A FORFF (07-18)
Child Care Administration
WITHDRAWAL OR TERMINATION REQUEST
REQUESTOR INFORMATION
Name (Last, First, M.I.)
Phone NO. (Include area code)
Address (No., Street)
City
State
ZIP Code
Client ID or Social Security Number
(Complete Sections A, B, and C)
A. I wish to withdraw or terminate:
My application for Child Care Assistance
My Child Care Assistance
My request for a fair hearing. I understand that if I received Child Care Assistance pending the outcome of a
hearing, I may be required to repay any benefits received for which I am not eligible.
B. Reason for withdrawal/termination:
Moving out of state to (State)
. Date of move (Month/Day/Year)
.
Other (explain):
C. I understand that this request will result in either the termination of my Child Care Assistance, the denial of my
application for Child Care Assistance, or the withdrawal of my request for a fair hearing.
Client’s Name (Last, First, M.I.)
Month/Day/Year
Client’s Signature
Month/Day/Year
Child Care Specialist’s Signature
Month/Day/Year
OFFICE USE ONLY
To be Completed by DES Child Care Specialist
D. Verbal withdrawal or termination request (to be completed by the Specialist along with Sections A and B when
the client’s request is received verbally).
Client’s Name (Last, First, M.I.)
Month/Day/Year
Child Care Specialist’s Signature
Month/Day/Year
Date of verbal request (Month/Day/Year)
In person
By telephone
Routing: Original – CCA, Copy – Client, Copy – Office of Appeals (if applicable)
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.