Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071431
- Contract number
- CTR071431
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form issued by the Arizona Department of Child Safety (DCS), specifically designed for tracking and returning unallocated child-related financial allowances. The form is intended to be used by service providers who have received payments for child care periods but did not distribute the full allowance amount to the intended child.
The form provides detailed instructions for providers to report and return unused allowances, with a structured template for capturing participant information including service dates, allowance type, and amount. The remittance is to be sent to the Arizona Department of Child Safety's Payment Processing Unit located in Phoenix, with specific guidelines noting that the form should only be used for returning allowances for periods when a child was in the provider's care, and not for reversing payments for periods of non-care, which are handled automatically through the Guardian system.
View the file
Other files
Show all 35
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .