Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071410
- Contract number
- CTR071410
- Issued by
- Arizona
About this file
This document is a Returned Allowances Reporting Form from the Arizona Department of Child Safety, specifically designed for tracking and returning financial allowances associated with child care services. The form is intended for use by service providers who have received payments for child care but need to return funds for periods when the allowance was not fully distributed or utilized.
The form provides a structured template for providers to document detailed information including participant details, service dates, allowance types, and amounts. The remittance instructions direct providers to submit the form to the Arizona Department of Child Safety's Payment Processing Unit located in Phoenix. The document was originally created on 05/25/2018 and was last updated on 07/28/2023, indicating ongoing refinement of the reporting process. Providers are explicitly instructed to use this form only for returning allowances for periods when a child was in their care, with other payment discrepancies to be handled through the Guardian system.
View the file
Other files
Show all 46
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .