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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Care AdministrationCCA1114A FOR FF (417)PLEASE
type or print
all informationCONTRACTOR ELIGIBILITY VERIFICATION
Section 1. Provider/Applicant Information
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In the verification section, provide relevant information about the individual or entity being verified.
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fa-053 - verification is of compliance.
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Details regarding the compliance status and any corrective actions taken must be reported on fa-053 - verification.
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