Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071430
- Contract number
- CTR071430
- 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 unused allowances for children in care. The form is intended for provider use, with a structured template for documenting participant information, service dates, allowance amounts, and remittance details. The document was created on 05/25/2018 and last updated on 07/28/2023, indicating ongoing refinement of the reporting process.
The form provides specific instructions for returning allowances not distributed to children during their care period, with a designated payment processing unit located in Phoenix, Arizona. Providers are required to complete the form with details including participant identification, service dates, allowance type and amount, and contact information. The document specifies that allowances for periods when a child was not in care should be handled through a system called Guardian, rather than using this specific reporting form. The remittance is to be sent to the Arizona Department of Child Safety's Payment Processing Unit at a designated PO Box in Phoenix.
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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 .