Form Cse-1165aforff - Acknowledgment Tracking printable pdf download

Form Cse-1165aforff - Acknowledgment Tracking

CSE-1165AFORFF (1-14)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Child Support Services

Page

ACKNOWLEDGMENT TRACKING

To be completed and returned at the end of every week.

HOSPITAL NAME

ADDRESS (No., Street, City, State, ZIP)

FOR THE WEEK ENDING

TOTAL NUMBER OF BIRTHS

TOTAL BIRTHS OUT OF WEDLOCK

MOTHER’S

FATHER’S

FORM

HPP

MOTHER’S NAME

FATHER’S NAME

NUMBER

SOC. SEC. NO.

ONLY

VERIFIED BY

DATE VERIFIED

For Hospital Paternity Program Use Only

Routing: Original – DCSS/Hospital Paternity Program, Copy – Hospital

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.

Form Cse-1165aforff - Acknowledgment Tracking