Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071437
- Contract number
- CTR071437
- Issued by
- Arizona
About this file
This document is an Arizona Department of Child Safety Returned Allowances Reporting Form, designed for tracking and returning financial allowances related to child care services. The form is specifically used by service providers to document and remit unallocated or unused allowance funds to the Arizona Department of Child Safety's Payment Processing Unit, located in Phoenix, Arizona.
The form provides a structured template for providers to record detailed participant information, including service dates, participant identification numbers, names, and specific allowance amounts. Providers are instructed to use this form exclusively for returning allowances paid for periods when a child was in their care but not distributed, with a clear directive that funds for periods when a child was not in care should be handled through a separate reversal process via Guardian. The form was last updated on 07/28/2023, indicating ongoing refinement of the tracking and reporting process.
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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 .