Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071405
- Contract number
- CTR071405
- Issued by
- Arizona
About this file
The document is an official Returned Allowances Reporting Form issued by the Arizona Department of Child Safety, dated 07/28/2023. The form is specifically designed for tracking and returning financial allowances for children in foster care or state custody, with a designated payment processing unit located in Phoenix, Arizona.
The form provides a structured template for providers to document unallocated or unused child allowances, requiring detailed participant information including service dates, participant identification numbers, names, allowance types, and amounts. Providers are instructed to use this form exclusively for returning allowances paid during periods when a child was in their care, with specific guidance that allowances for periods outside of care should be handled through an automated system called Guardian. The form includes remittance instructions and is to be submitted 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 .