Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071406
- Contract number
- CTR071406
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form issued by the Arizona Department of Child Safety, specifically designed for tracking and returning unallocated allowances for children in care. The form is meant to be submitted by care providers, with a standardized format for reporting participant information, service dates, and allowance details. The document was last updated on 07/28/2023 and provides specific remittance instructions to the Payment Processing Unit located in Phoenix, Arizona.
The form serves as a mechanism for providers to return monetary allowances that were not distributed to children during specified service periods. It includes fields for capturing critical information such as participant identification, names, service start and end dates, allowance type, and amount. The document emphasizes that the form should only be used for returning allowances for periods when a child was actually in the provider's care, with other unallocated funds to be automatically processed through a system called Guardian. The form includes a mailing address for submission to the Arizona Department of Child Safety's Payment Processing Unit.
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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 .