Form Cse-1156a - Affidavit Of Receipt Of Direct Payments
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Vea instrucciones
Michael Trailor
Douglas A. Ducey
Governor
Director
AFFIDAVIT OF RECEIPT OF DIRECT PAYMENTS
AFIDÁVIT DEL RECIBO DE PAGOS DIRECTOS
My name is:
Mi nombre es:
_____________________________________
I receive support in ATLAS case number:
Yo recibo sustento en número de caso ATLAS: _____________________________________
The court case number is:
El número de caso de tribunal es:
_____________________________________
Court county and state:
El condado y estado del tribunal:
_____________________________________
Name of person obligated to pay support:
Nombre del padre obligado de pagar sustento:
_____________________________________
I am completing this Affidavit of Receipt of Direct Payments voluntarily, and not under duress or as a
result of any coercion or threats made by anyone. I also understand that once this Affidavit is signed,
notarized and delivered to the Division of Child Support Services (DCSS), it is IRREVOCABLE
and I cannot change my mind.
Yo lleno Afidávit del Recibo de Pagos Directos, de manera voluntaria y no bajo dispensa de coacción ni de
resultas coerción ni porque me han amenazado. Además, entiendo que una vez que lo firme y haga certificado
por notario el Afidávit del Recibo de Pagos Directos y se le haga entregado a la División de Servicios de
Sustento para Menores (DCSS), SERÁ IRREVOCABLE yo no puedo cambiar de parecer.
I understand that DCSS and its agents do not represent me in this matter and that I can consult an
attorney before executing this Affidavit of Receipt of Direct Payments, and that I have had the
opportunity to consult an attorney before signing this Affidavit.
Yo entiendo que la DCSS y sus agentes no me representan en este asunto y que antes de llevar a cabo el
Afidávit del Recibo de Pagos Directos, yo puedo consultar con un abogado y que se me ha dado la
oportunidad de consultar con un abogado antes de firmar este Afidávit del Recibo del Pagos Directos.
CSE-1156AFORPF (12-17)
Page 1 of 4
P.O. BOX 40458, PHOENIX, AZ 85067-0458
Telephone (602) 252-4045 • Fax (602) 248-3126 •
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