Form Cse-1157a Forpf - Non-Custodial Parent Request For Administrative Review/solicitud De Padre/madre Sin La Custodia Para Una Revision Administrativa Page 2

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FCSE0001 F0347 W
CSE-1157A FORPF (4-17) - Page 2 / Página 2
I have attached the following information to prove my claim:
He adjuntado la siguiente información para demostrar mi reclamo:
Canceled checks or receipt(s) for child support payments made directly to the other parent.
Cheques cancelados o recibo(s) de pagos de sustento de menores hechos directamente al otro padre.
Signed/notarized statement(s) by the custodial person about direct payments.
Declaración(es) firmadas/notariadas por la persona con la custodia sobre pagos directos.
Birth / death / marriage certificates.
Certificados de nacimiento/defunción/matrimonio.
Court order with a change to the amount of child support, a change of custody or an adoption.
Orden judicial con un cambio en la cantidad de sustento de menores, un cambio en la custodia o una adopción.
School or daycare record(s) showing that I have legal custody.
Documento(s) de la escuela o de una guardería infantil demostrando que yo tengo la custodia legal.
Other document(s) that will assist DCSS
Otro(s) documento(s) que ayudarán a DCSS
Signature of person requesting administrative review / Firma de la persona solicitando una revisión administrativa
Date / Fecha
SEND COMPLETED FORMS TO: / ENVÍE LOS FORMULARIOS COMPLETOS A:
DCSS Administrative Review Unit
P.O. Box 40408
Phoenix, AZ 85067
Fax: 602-771-8398
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.
Programa y Empleador con Igualdad de Oportunidades • Bajo los Títulos VI y VII de la Ley de los Derechos Civiles
de 1964 (Títulos VI y VII) y la Ley de Estadounidenses con Discapacidades de 1990 (ADA por sus siglas en inglés),
Sección 504 de la Ley de Rehabilitación de 1973, Ley contra la Discriminación por Edad de 1975 y el Título II de la Ley
contra la Discriminación por Información Genética (GINA por sus siglas en inglés) de 2008; el Departamento prohíbe la
discriminación en la admisión, programas, servicios, actividades o empleo basado en raza, color, religión, sexo, origen,
edad, discapacidad, genética y represalias. Para obtener este documento en otro formato u obtener información adicional
sobre esta política, llame al 602-252-4045; Servicios de TTY/TDD: 7-1-1. • Ayuda gratuita con traducciones relacionadas a
los servicios del DES está disponible a solicitud del cliente.

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