Claims - About Forms 110A and 110B

Claims Division About Forms 110A and 110B

Ruby Tate, Claims Manager
Email: [email protected]
Phoenix: 800 W Washington St, Phoenix AZ 85007 - Phone: (602) 542-4661
Tucson: 2675 East Broadway, Tucson AZ 85716 - Phone: (520) 628-5181
FAX (use for either office): (602) 542-3373

Phone List of ICA Divisions


About Forms 110A and 110B

The Commission has revised two forms, the Worker’s Annual Report of Income, Form 110-A, and the Notice of Intent to Suspend, Form 110-B. The Commission revised these forms to include the statement mandated by House Bill 2331, 52nd Legislature, First Regular Session, (A.R.S. § 23-1028(D)), and for minor non-substantive changes.

The statement that has been added to these forms reads: “Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one half years in prison, a fifty thousand dollar fine and forfeiture of benefits. By my signature below, I am applying for all benefits to which I may be entitled and I swear that the statements made on this application are true, correct and complete to the best of my knowledge.”

The requirement that reports of income include the statement is effective on July 3, 2015. Both revised forms Form 110-A and 110-B contain a revision date of 6/2015 in the lower left-hand corner and the use of all previous versions of the forms should be discontinued. Questions regarding the new forms should be directed to the Claims Division at (602) 542-4661.

Both of these forms may be downloaded directly from this website:

Click on a link below to obtain

Form 110A: Annual Report of Income

Form 110B: Notice of Intent to Suspend