INSTRUCTIONS: ARIZONA WITHDRAWAL OR TERMINATION REQUEST FOR CHILD CARE PROVIDERS (Form CCA-1170A)

Arizona child care providers who wish to have their certification terminated or application for certification withdrawn should complete a form CCA-1170A. This document can be obtained from the website maintained by the Arizona Department of Economic Security. Note that this form is provided as a text document. You are required to complete this document by typing your answers on a word processor. Note that you may also submit this request verbally. If so, this document will be completed by the official you speak with.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 1: In the first box, enter your last name, first name and middle initial.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 2: in the second box, enter your phone number, including the area code.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 3: Check Section A if you wish to withdraw your request for a fair hearing.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 4: Check Section B if you wish to withdraw your request to become a DES certified family care provider. Note that checking this box will result in either the closure or denial of your application.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 5: Check Section C if you wish to terminate your DES child care certification. Note that this may result in the revocation of your certification. You must either attach your DES certificate or surrender it within seven days of termination. Indicate with a check mark which course of action you are taking.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 6: Check Section D if you wish to terminate your NCRP registration agreement.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 7: In the section where indicated, write your reason for withdrawing your request or wishing to terminate your certification.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 8: In the blank box below this section, enter your signature.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 9: In the blank box to the right of this, enter the date.