Exhibit VI Fees Log.pdf
PDF 82 KB Posted
- Attached to
- Master Agreement AZ|CTR071411
- Contract number
- CTR071411
- Issued by
- Arizona
About this file
This document is an Arizona Department of Child Safety Congregate Care Fees Log (Exhibit VI) designed to track and document educational and school-related fees and fines for children in out-of-home care. The form is dated 05/24 and provides a standardized template for recording financial transactions, with designated spaces for child information, payment details, and required signatures from both the child (if 12 years or older) and staff.
The log is structured to systematically record each payment or outstanding fine, including columns for date, description of payment, payment method, amount, and dual signatures. It requires attaching receipts and ensures accountability for educational expenses. The form is intended to create a transparent and comprehensive record of financial transactions for children in congregate care settings, with spaces for an audit signature and out-of-home provider's signature to validate the accuracy and completeness of the recorded information.
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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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