Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071448
- Contract number
- CTR071448
- 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 allowances. The form is intended for providers who have received payments for child care services during specific service dates but did not distribute the full allowance amount to the child.
The form provides a structured template for reporting unused allowances, with sections for participant information, service dates, allowance type, and amount. The remittance instructions direct providers to submit the form to the Arizona Department of Child Safety's Payment Processing Unit in Phoenix, with specific guidelines about when and how to return undistributed funds. The document was originally created on 05/25/2018 and was last updated on 07/28/2023, indicating an ongoing 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 .