Exhibit VI Fees Log.pdf
PDF 82 KB Posted
- Attached to
- Master Agreement AZ|CTR071409
- Contract number
- CTR071409
- Issued by
- Arizona
About this file
This document is an Exhibit VI Congregate Care Fees Log form from 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 a standardized administrative tool used to record financial transactions and ensure accountability for school-related expenses for children placed in congregate care facilities.
The log provides a structured template for recording each payment or outstanding fine, with designated columns for date, description of payment, payment method, amount, and signatures from both the child (if 12 years or older) and staff. The form requires attaching receipts and includes spaces for an audit signature and the out-of-home provider's signature. Its primary purpose is to create a transparent, documented record of all educational expenses incurred by children in the care of the Arizona Department of Child Safety, ensuring proper financial management and tracking of school-related costs.
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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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