Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071434
- Contract number
- CTR071434
- 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 allowances not distributed to children during specific service periods. The form is intended for use by providers who have received payments for child care services and need to report unallocated funds. The document provides remittance instructions, directing providers to submit returned allowances to the Payment Processing Unit in Phoenix, Arizona.
The form captures detailed participant information including service dates, allowance types, amounts, and personal identifiers. Providers are instructed to use the 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 document was last updated on 07/28/2023, originally created on 05/25/2018, and includes contact information for processing payments and submitting returned funds.
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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 .