Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071450
- Contract number
- CTR071450
- 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 allowances not distributed to children during specific service periods. The form is to be used by care providers when they need to return funds for periods when a child was in their care but did not receive the allocated allowance.
The form provides specific instructions for remitting returned allowances, with payment to be processed through the Arizona Department of Child Safety's Payment Processing Unit located in Phoenix. The document was last updated on 07/28/2023 and originally created on 05/25/2018, indicating an ongoing administrative process for managing child care financial allocations. The form requires detailed participant information including service dates, allowance type, amount, and personal identifying details, to be submitted to the designated payment processing address.
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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 .