Form Cse-1196a - Notification Of Employment Termination
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DEPARTMENT OF ECONOMIC SECURITY
Your Partner For A Stronger Arizona
CSE-1196A LTHFF (6-17)
Douglas A. Ducey
Michael Trailor
Governor
Director
NOTIFICATION OF EMPLOYMENT TERMINATION
CSE AGENCY CASE IDENTIFIER (ATLAS NUMBER)
ORDER IDENTIFIER
EMPLOYEE’S NAME (Last, First, M.I.)
SOCIAL SECURITY NO.
EMPLOYER’S NAME
FEIN
DATE OF TERMINATION
DATE OF FINAL PAYMENT TO THE STATE DISBURSEMENT UNIT
FINAL PAYMENT AMOUNT
$
EMPLOYEE’S LAST KNOWN ADDRESS (No., Street)
CITY
STATE
ZIP CODE
LAST KNOWN PHONE NO.
NEW EMPLOYER’S NAME
NEW EMPLOYER’S ADDRESS
If you have any questions, contact DCSS Customer Service: Phone: (602) 252-4045, toll free at 1(800) 882-4151, or visit
our website at
https://des.az.gov/services/child-and-family/arizona-child-support-services
Print and send Termination Notice to:
Division of Child Support Services
P.O. Box 40458 / Mail Drop 7413
Phoenix, AZ 85067
Or Fax to: (480) 926-5193
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. The Department must make a reasonable accommodation to allow a person with a disability to take
part in a program, service or activity. For example, this means if necessary, the Department must provide sign language
interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the
Department will take any other reasonable action that allows you to take part in and understand a program or activity,
including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a
program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To
request this document in alternative format or for further information about this policy, contact (602) 252-4045; TTY/TDD
Services: 7-1-1. • Free language assistance for DES services is available upon request. • Ayuda gratuita con traducciones
relacionadas con los servicios del DES está disponible a solicitud del cliente.
M/D 7413 • PO BOX 40458 Phoenix, AZ 85067 • Telephone (602) 252-4045, toll free 1-800-882-4151 • https://des.az.gov/
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