Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071422
- Contract number
- CTR071422
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form issued by the Arizona Department of Child Safety, designed for tracking and returning unallocated child-related financial allowances. The form is specifically intended for providers who have received payments for periods when a child was in their care but did not distribute the full allowance amount. The form provides a structured template for reporting, with designated sections for participant information, service dates, allowance types, and contact details.
The reporting form includes instructions for providers to remit unspent allowances to the Arizona Department of Child Safety's Payment Processing Unit, located in Phoenix. The document was last updated on 07/28/2023, with an original creation date of 05/25/2018, and requires providers to specify details such as participant identification numbers, names, service start and end dates, allowance types, and amounts. The form emphasizes that it should only be used for returning allowances for periods when a child was actually in the provider's care, with other unallocated payments to be handled through a system called Guardian.
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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 .