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D D CCA-1140A FORFF (3-16) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Child Care Administration DIRECT DEPOSIT ENROLLMENT CENTERS AND GROUP HOMES Initial Request Change Request P r o v i d e r

I n f o r m a t i o n

f o r

D i r ect D eposit Enrollment I authorize the State of Arizona and the financial institution to process credit entries to the bank account number stated on this form. I will notify the State of Arizona of any known changes or closure of my bank account. When the State of Arizona is notified by my financial institution of changes affecting this direct deposit, the State of Arizona is authorized to make the applicable changes. This authorization is to remain in effect until a new authorization is received. SIGNATURE DATE Please submit this form with a copy of a voided check to: Department of Economic Security Child Care Administration Payment Processing Unit P.O. Box 6123, 944C Phoenix, AZ 85005 NOTE: Your enrollment cannot be processed without a copy of a voided check attached. Please allow 60 days for Direct Deposit to start. Thank you. 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 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente. CCA-1140A (4-16) – Page 39 Arizona Department of Economic Security