Exhibit VI Fees Log.pdf
PDF 82 KB Posted
- Attached to
- Master Agreement AZ|CTR071423
- Contract number
- CTR071423
- Issued by
- Arizona
About this file
This document is a Congregate Care Fees Log form issued by the Arizona Department of Child Safety (DCS), designed to track and document educational and school-related fees and fines for children in out-of-home care. The form is an official Exhibit VI dated 05/24, intended to be used by providers and staff to record financial transactions and ensure proper documentation of school-related expenses.
The log provides a structured template for recording detailed information about payments, including date, description of payment, payment method, amount, and requiring signatures from both the child (if 12 years or older) and staff. The form mandates that all fees and fines related to educational activities be paid and documented, with the expectation that receipts will be attached to the log. The document allows for multiple entries of payments and outstanding fines, providing a comprehensive tracking mechanism for financial transactions associated with a child's educational needs while in congregate care.
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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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