Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071666
- Contract number
- CTR071666
- 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 child-related allowances. The form provides a structured mechanism for providers to report and return funds that were paid for a period when a child was in their care but not actually distributed to the child.
The form includes fields for capturing detailed participant information such as provider name, provider ID, service dates, participant identification number, participant name, allowance type, and amount. The document specifies that allowances should only be returned for periods when the child was in the provider's care, with other unallocated periods to be automatically reversed through the Guardian system. Remittance is to be made to the Arizona Department of Child Safety's Payment Processing Unit located in Phoenix, Arizona, with the form updated as of 07/28/2023 and originally created on 05/25/2018.
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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 .