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CCA-1021AFORNA UNPAID CO-PAYMENT WORKSHEET 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 A ct of 1973, the Age Discrimination A ct of 1975, and Title II of the Genetic Information Nondiscrimination A ct (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, ac

tivities, 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 ne

eds 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 a los servicios del DES está disponible a solicitud del cliente. Page 54 CCA-1021A (11-11) – Arizona Department of Economic Security