Form Cse-1249a Forff - Referral
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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CSE-1249A FORFF (4-17)
Division of Child Support Services (DCSS)
REFERRAL
Maricopa County only
3146 E. Wier Ave., # 26, Phoenix, AZ 85040 ─ Call (602) 774-3298 / Fax (602) 243-2145 or email
PARTICIPANT INFORMATION
Name
Phone Number
Email Address
REASON(S) FOR REFERRAL (check all that apply)
Parenting Classes
Healthcare Enrollment (AHCCCS or Marketplace)
Support Groups
Emergency Baby Bag
SNAP (Food Stamps) Enrollment
Mentoring Services
Family Law Services
Hygiene Kit
Employment Assistance
Other (specify in Comments section)
Case Management
Comments:
REFERRAL AGENCY
Person’s Name Making Referral
Referral Date
Agency
Phone Number
Note: Anyone being referred will receive a call within 48 hours from the date of the referral.
REFERRING DCSS OFFICE
North Maricopa Regional Office (NVO)
East Maricopa Regional Office (EVO)
North Balance of State (NBOS)
South Balance of State (SBOS)
Pinal County
Other:
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 the
Division of Child Support Services at (602) 252-4045: 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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