Form Cse-1277a - Return Documents Form
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CSE-1277A FORFF (6-17)
Division of Child Support Services
RETURN DOCUMENTS FORM
Douglas A. Ducey
Michael Trailor
Governor
Director
PERSONAL INFORMATION
DATE
ATLAS/AZTEC#
TANF
INTAKE OFFICER NAME
CUSTODIAL PARENT NAME
NON-CUSTODIAL PARENT NAME
PLEASE RETURN THIS FORM WITH THE FOLLOWING DOCUMENTS BY
DATE:
1. BIRTH CERTIFICATE FOR:
You
All Children
The Following Children
2. SOCIAL SECURITY CARD FOR:
You
All Children
The Following Children
3. OTHER
Marriage Licence
Divorce Decree
Death Certificate or proof of Death for Non Custodial Parent
Paternity/Child Support Orders
Address Confidentiality Program ID Card (If applicable)
4. MAIL TO
PLEASE RETURN THIS FORM WITH YOUR DOCUMENTS TO:
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
FAX
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
602-252-4045; 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 esta disponible a solicitud del cliente.
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