Exhibit X Returned Allowances Form.xlsx
XLSX spreadsheet 20 KB Posted
- Attached to
- Master Agreement AZ|CTR071445
- Contract number
- CTR071445
- 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 allowances not distributed to children during their care periods. The form is intended for providers to report and remit unallocated funds, with instructions to submit the document to the Payment Processing Unit located in Phoenix, Arizona.
The form provides a structured template for providers to document participant information, including service dates, allowance types, amounts, and personal details. The form requires completion of fields such as Provider Name, Provider ID, Participant Name, Service Start and End Dates, Allowance Type, and Amount. The document was last updated on 07/28/2023, with an original creation date of 05/25/2018, and includes specific remittance instructions to the Arizona Department of Child Safety's payment processing address.
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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 .