Form As 067 PDF Details

In navigating the complexities of financial obligations to the Arizona Department of Economic Security (DES), individuals encounter the AS-067 form, a pivotal document designed to streamline the monthly reporting and payment processes for accounts receivable and collections. This document serves a dual purpose: to provide account holders with a detailed statement of their monthly financial responsibilities to the Department and to facilitate a hassle-free payment process. Each section of the form, from the account number and billing month to the specific program type and total amount due, is meticulously drafted to ensure clarity and ease of understanding for the payer. It is crucial for account holders, particularly those making payments for child support or other family-related financial obligations, to familiarize themselves with every aspect of the AS-067 form. Understanding the breakdown of accumulated unpaid balances, current month charges, and total amount due, along with the significance of each program type code ranging from Jobs Program and Aid to Families with Dependent Children to Unemployment Insurance Benefit reflect the form's comprehensive nature. Furthermore, the form accommodates various payment methods and provides crucial instructions for those preferring to go paperless, enhancing convenience and ensuring timely payments. With delinquency carrying significant repercussions, including potential interception of federal income tax refunds or other benefits for certain programs, the importance of adhering to the specified due dates cannot be overstated. Additionally, the form aligns with the Arizona Department of Economic Security's commitment to nondiscrimination and accessibility, affirming its dedication to serving all residents equitably. Thus, the AS-067 form emerges as a cornerstone document for individuals engaged with the DES, facilitating not only the fulfillment of financial obligations but also reinforcing the transparent and accessible nature of governmental departmental processes.

QuestionAnswer
Form NameForm As 067
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesextranet azdes gov dcyf childs ebilling, dcyf billing, extranet azdesgovchildsebilling, az dcs billing

Form Preview Example

AS-067 (03/10)ATTACHMENT #1

Arizona Department of Economic Security Office of Accounts Receivable and Collections P.O. Box 504097, St. Louis, Missouri 63150-4097 (602) 252-0024 or 1-800-236-1475

MONTHLY STATEMENT OF ACCOUNT

DES ACCOUNT NO: A

AZTECS NO.:

MONTH: B

 

 

(agent first name & last name initial) C

(direct phone number)

DUE DATE:

 

NAME

DADDRESS

CITY, STATE ZIP CODE

KEY

A)Account Number B) Month of Billing C) Office of Accounts Receivable Collections Agent/Phone Number assigned to the account; families are to use this person for setting up on line payments D) Name, Address, and Phone Number of Responsible Person that will be making payments for child E) Program Number - AzEIP is 45, DDD is 44 F) Accumulated Unpaid Balances prior to current month billing G) Current Month Charges H) Total Amount

 

 

 

 

 

Due for the account

 

 

PROG.

PREVIOUS

DEBTS/INT./

CASH

NUTRITION

RECOUP.

CREDIT/

TOTAL

ENDING

TYPE

BALANCE

ADJUST.

PAID

ASSISTANCE

OFFSET

ADJUST.

REFUNDS

BALANCE

E

F

G

H

TOTALS

See reverse for an explanation of the PROGRAM TYPE codes.

(KEEP THIS UPPER PROTION FOR YOUR RECORDS)

(PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT)

NAME:

TOTAL AMOUNT ENCLOSED: ________________

D.E.S. ACCOUNT NO.:

 

Visit our website at https://az.gov/app/desops to make on-line payments or make your check or money orders payable to the Department of Economic Security and return it in the envelope provided to: Arizona Department of Economic Security, Office of Accounts Receivable and Collections, P.O. Box 504097, St. Louis, MO 63150-4097. Write your DES Account No. on your payment.

If you would like your payment applied to a specific program type, please enter it in the box.

Program Type No.

Individual account holders may sign-up today at https://egov.azdes.gov/dbf/estatment to go paperless. You will receive e-mail notification when your bill is ready to view.

MONTH:

*************************************************************************************************************

*************************************************************************************************************

Explanation of PROGRAM TYPE codes:

01 - Jobs Program – (JOBS)

02- Aid to Families with Dependent Children/Cash Assistance – (AFDC – CA)

05- General Assistance (GA)

06- Child Care (Subsidy, AFDC, Risk Title IV, CCDBg) – (CC)

08- Division of Children, Youth and Families (DCYF), Foster Care Provider – (FC)

10- Legal and Other Related Fees – (LF)

15- Audits/Misc. Debts (MISC)

20- Employee Overpayment/Payroll/Travel – (EOP)

21- Tuition Assistance/Stipend (TAP)

23- Refugee Resettlement Program – (RRP)

24- DDD Provider Overpayment (DDPO)

28- Nutrition Assistance (formerly the Food Stamp Program) - (NA)

30- Foster Care Parental Assessment – (PA)

40- Division of Developmental Disabilities Fee for Services – (SF)

41- Division of Developmental Disabilities Residential Billing – (RS)

42- Division of Developmental Disabilities ALTECS Billing – (AL)

43- Division of Developmental Disabilities Estates, Trust and Annuity Billing – (ETA)

44- Division of Developmental Disabilities Early Intervention Program – DDD (DEI)

45- Department of Economic Security Arizona Early Intervention Program – DES (EIP) 50/59 - Temporary Assistance for Needy Families/Cash Assistance – (TANF/CA)

61- Jobs Program/Maximus – (JOBS)

65- General Assistance Benefits/Maximus – (GA)

70- Unemployment Insurance Benefit – (UIB)

The new balance shown on the front of this statement is calculated as of the last day of the month. Payments, offsets, and other adjustments posted after that day will be included on your next statement. Mail your payment or make on-line payments at https://az.gov/app/desops by the 15th of the month to avoid delinquency. If you do not pay by the DUE DATE your account will be considered delinquent. For Nutrition Assistance (28) and Unemployment Insurance Benefit (70) delinquencies, the Department may intercept your Federal income tax refund, Social Security benefits, or any other Federal payment you may be entitled to receive and apply it to your account balance.

The enclosed envelope is for PAYMENTS ONLY. Address changes may be made at https://egov.azdes.gov/dbf/estatement. Correspondence or inquiries may be e-mailed to OARC@azdes.gov or write to us at:

Arizona Department of Economic Security

Office of Accounts Receivable and Collections (833C)

P.O. Box 60

Phoenix, AZ 85001-0060

To contact our Customer Service and Collections Department, call 602-252-0024 or toll free at 1-800-236-1475 outside the Phoenix metropolitan area but within the State of Arizona.

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 602-252-0024; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.

AS-067 (01/12) REVERSE

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