Exhibit VI Fees Log.pdf
PDF 82 KB Posted
- Attached to
- Master Agreement AZ|CTR071444
- Contract number
- CTR071444
- Issued by
- Arizona
About this file
This document is a Congregate Care Fees Log form created by the Arizona Department of Child Safety (DCS), dated May 24th. The form is designed to track and document educational and school-related fees and fines for children in out-of-home care placements.
The form provides a structured template for recording individual payments and outstanding fines, with columns for date, description of payment, payment method, amount, and signatures from both the child (if 12 years or older) and staff. The purpose is to ensure transparency and accountability in managing school-related expenses for children in congregate care settings, with an expectation that receipts will be attached to substantiate the recorded transactions. The log includes spaces for recording the child's name, date of birth, provider's name, facility name, placement date, and an audit signature section.
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Text version
CONGREGATE CARE
FEES LOG
ARIZONA DEPARTMENT OF CHILD SAFETYExhibit VI (05/24)
Date Description of Payment Payment Method
Amount
Signature (signed by both Child and Staff)
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Payment
Outstanding Fine
Date of Birth Placement Date Date Log StartedProvider's Name | Facility Name
Exhibit VI
Child's Name (Last, First, M.I.)
Ensure all fees and or fines, related to educational and school activities are paid and documented on the child(ren)s Fee Log as required by the child(ren) s school. Receipts should be attached to this log
Date Date
Date
Audit Signature
Child's Signature (if child is 12 years old or older)
Out-of-Home Providers Signature
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