Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071415
- Contract number
- CTR071415
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form issued by the Arizona Department of Child Safety, designed to track and process unallocated allowances for children in care. The form provides a standardized method for care providers to return funds that were paid for a period when a child was in their care but not distributed to the intended recipient. The document includes fields for participant information, service dates, allowance type, and amount, with remittance instructions to the Payment Processing Unit in Phoenix, Arizona.
The form is structured to facilitate financial reconciliation for child care services, with specific guidelines that mandate providers only use this form for returning allowances during periods of active child care. The document does not outline a specific contract value or pricing structure, but serves as an administrative tool for tracking and returning unallocated funds. The form was last updated on 07/28/2023, indicating ongoing refinement of the reporting process, and provides contact information for submission and processing of returned allowances through the Arizona Department of Child Safety's payment system.
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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 .