Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071425
- Contract number
- CTR071425
- Issued by
- Arizona
About this file
The document is a Returned Allowances Reporting Form from the Arizona Department of Child Safety, designed for tracking and returning unallocated allowances for children in care. The form is specifically intended for service providers to document and return funds that were paid for a period when a child was in their care but not distributed. The form provides a structured template for capturing participant information, service dates, allowance details, and remittance instructions, with the payment processing unit located in Phoenix, Arizona.
The form requires providers to complete detailed information including participant identification, service start and end dates, allowance type and amount, and contact information. It explicitly instructs providers to only use the form for returning allowances for periods when a child was in their care, with other unallocated periods to be automatically reversed through the Guardian system. The document was last updated on 07/28/2023, indicating an ongoing administrative process for managing child care financial allocations within the Arizona Department of Child Safety's administrative framework.
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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 .