Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071444
- Contract number
- CTR071444
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form issued by the Arizona Department of Child Safety, designed for tracking and returning unallocated allowances for children in care. The form is specifically intended for providers to report and return financial allowances that were not distributed to a child during a specific service period, with instructions to submit the form to the agency's Payment Processing Unit located in Phoenix, Arizona.
The form requires detailed participant information including participant identification number, name, service dates, allowance type, and amount. It provides a structured mechanism for financial reconciliation, with a remittance address at the Arizona Department of Child Safety Payment Processing Unit. The document was last updated on 07/28/2023, originally created on 05/25/2018, and includes specific guidelines about when and how to use the form for returning unspent 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 .