INSTRUCTIONS: ARIZONA RESPONSE BY RELATIVE OR PERSON HAVING A SIGNIFICANT RELATIONSHIP WITH THE CHILD (Form CPS-1044B)

When Arizona Child Protection Services is charged with placing a child in custody in a new home, a form CPS-1044B may be mailed to relatives or persons who have a significant relationship with the child. The purpose of this form is to determine if you would be willing as a placement option. This document can be viewed on the website of the Arizona Department of Economic Security.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 1: On the first blank line, enter your name and your relationship to the children.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 2: On the second blank line, enter the name of the children.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 3: Check the first box if you wish to be considered as a placement option now.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 4: Check the second box if you wish to be considered as a placement option in the future.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 5: Check the third box if you are unsure if you wish to be considered as a placement option.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 6: Check the fourth box if you do not wish to be considered as a placement option.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 7: If you wish to be involved, enter the date by which you wish to be involved on line 2.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 8: On line 3, indicate with a check mark whether or not you would like to speak with a child protective services specialist about the children. If so, enter your telephone number or email address for contact purposes.

Arizona Response By Relative Or Person Having A Significant Relationship With The Child CPS-1044B Step 9: Sign and date the bottom of the form and provide all contact information requested.