Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071440
- Contract number
- CTR071440
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form issued by the Arizona Department of Child Safety, specifically designed for tracking and returning allowances not distributed to children during foster care placements. The form is intended to be used by foster care providers to report and return unallocated funds, with submission directed to the Payment Processing Unit in Phoenix, Arizona.
The form provides a structured template for providers to document participant information including service dates, allowance types, amounts, and personal details. It specifies that providers should only use this form for returning allowances paid for periods when a child was in their care, with alternative processing through Guardian for other scenarios. The form was originally created on 05/25/2018 and was most recently updated on 07/28/2023, indicating ongoing refinement of the reporting process for child welfare financial tracking.
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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 .