Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071443
- Contract number
- CTR071443
- Issued by
- Arizona
About this file
The document is an official Arizona Department of Child Safety Returned Allowances Reporting Form, updated on 07/28/2023, designed for tracking and returning unallocated child care allowances. The form is specifically used by care providers to report and return financial allowances that were not distributed to children during designated service periods, with the remittance to be sent to the Payment Processing Unit in Phoenix, Arizona.
The form provides a structured template for providers to document detailed participant information, including service dates, allowance types, amounts, and personal identification details. Providers are instructed to use this form exclusively for returning allowances paid during periods when a child was in their care, with specific guidance that allowances for periods when a child was not in care should be reversed through the Guardian system. The form includes a remittance address at the Arizona Department of Child Safety's Payment Processing Unit and indicates a standardized process for financial reconciliation of child care allowances.
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Text version
Returned Allowances Tracking
| Provider Name: | Date: | |||||
| Provider ID: | ||||||
| Total: | $0.00 | |||||
| Participant Information | Service Dates | Allowances | ||||
| PI Number | Last Name | First Name | Start Date | End Date | Type | Amount |
Contact Person: Remit to: Arizona Department of Child Safety Payment Processing Unit PO Box 6030, Site Code C010-01 Phoenix, AZ 85005-6030
| Phone #: |
| E-mail: |
*Use this form to return allowances that were not distributed to the child, but were paid for a period when the child was in your care. Do not use this form to return allowances paid for periods when the child was not in your care. Those should be reversed and automatically collected through Guardian.
&"-,Bold"&14Arizona Department of Child Safety Returned Allowances Reporting Form*
Updated 07/28/2023 Created 05/25/2018
File details come from the government source that posted it. Updated .