Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071423
- Contract number
- CTR071423
- Issued by
- Arizona
About this file
This 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 that were paid for children in care but not distributed to the intended recipients. The document provides remittance instructions for submitting returned funds to the Payment Processing Unit located in Phoenix, Arizona.
The form captures detailed participant information including service dates, allowance types, amounts, and personal identifiers. It includes specific guidance for providers on when and how to return unallocated allowances, with a clear directive to only use the form for funds paid during periods when a child was in care. The document provides a structured method for financial reconciliation within the child welfare system, with a payment remittance address and instructions for proper documentation of returned funds.
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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 .