Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071416
- Contract number
- CTR071416
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form from the Arizona Department of Child Safety, designed for tracking and returning unallocated child-related financial allowances. The form is specifically intended for use by service providers who have received payments for child care periods but did not distribute the full allowance amount to the designated child.
The form provides a structured template for reporting unspent allowances, with fields for participant information including service dates, allowance type, and amount. The remittance instructions direct providers to submit the completed form to the Arizona Department of Child Safety's Payment Processing Unit located in Phoenix, with a mailing address of PO Box 6030, Site Code C010-01. The document was last updated on 07/28/2023, with an original creation date of 05/25/2018, indicating an established administrative process for managing child care financial allocations.
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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 .