Form Cc-031a - Verbal Notice Of Eligibility
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1
2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CC-031A FORFF (8-17)
Child Care Administration
VERBAL NOTICE OF ELIGIBILITY
VERBAL NOTICE INFORMATION
DATE VERBAL NOTICE RECEIVED
DOCUMENTED BY
DES/CCA SPECIALIST’S NAME
PHONE NO.
PARENT/CARETAKER’S NAME
CHILD’S NAME
CHILD’S ID#
START DATE
STOP DATE
#OF UNITS
COPAY AMOUNT
D
D
L
L
D
D
L
L
D
D
L
L
D
D
L
L
D
D
L
L
D
D
L
L
D
D
L
L
• If a Certificate of Authorization form is not received after ten (10) working days of receiving a verbal notification of
eligibility,contact the child’s Case Specialist to request a copy of the child’s CP08A Client/Provider Action/Authorization
Notice, “Turn-Around Document”.
• The copay amount is the minimum payment expected for each child and is set by DES/CCA. The amount you actually
charge a family for care (your charges minus what DES/CCA pays) may be greater than the copay amount.
• “D” Full Day = 6 hours or more, “L” = Less than 6 hours = Part Day.
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 602-542-4348; TTY/TDD
Services: 7-1-1. • Free language assistance for DES services is available upon request. • Español al reverso.
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