Exhibit VI Fees Log.pdf
PDF 82 KB Posted
- Attached to
- Master Agreement AZ|CTR071426
- Contract number
- CTR071426
- Issued by
- Arizona
About this file
This is a Congregate Care Fees Log form issued by the Arizona Department of Child Safety (DCS), designated as Exhibit VI and dated 05/24. The document is a standardized tracking form designed to document and record educational and school-related fees and fines for children in out-of-home care placements.
The form provides a structured template for logging individual payments and outstanding fines, with columns for date, payment description, payment method, amount, and requiring signatures from both the child (if 12 years or older) and staff. The form mandates that all educational and school activity fees must be documented and that receipts should be attached to the log. The document includes spaces for recording the child's name, date of birth, provider's name, facility name, placement date, and includes signature lines for audit and out-of-home provider verification.
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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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