Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071409
- Contract number
- CTR071409
- 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 not distributed to children during periods of foster care, with instructions for providers to submit documentation to the agency's Payment Processing Unit located in Phoenix, Arizona.
The form provides a structured template for foster care providers to report unallocated allowances, requiring detailed participant information including service dates, participant identification numbers, names, and specific allowance amounts. Providers are instructed to use the form exclusively for returning funds paid for periods when a child was in their care, with alternative processing through Guardian for other scenarios. The document includes remittance instructions and contact information for the Arizona Department of Child Safety's payment processing division.
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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 .