Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071424
- Contract number
- CTR071424
- Issued by
- Arizona
About this file
The document is a Returned Allowances Reporting Form issued by the Arizona Department of Child Safety, dated 07/28/2023. The form is designed for tracking and returning allowances not distributed to children during specific service periods, with a standardized template for providers to report unallocated funds.
The form provides specific instructions for providers to report unused allowances, with a remittance address to the Arizona Department of Child Safety Payment Processing Unit in Phoenix. The document includes fields for capturing participant information such as service dates, allowance type and amount, personal identification numbers, and contact details. Providers are explicitly instructed to use this form only for returning allowances for periods when a child was in their care, with other unallocated funds to be automatically reversed through the Guardian system.
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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 .