APPLICATION AND MANAGEMENT PLAN.PDF

Arizona Department of Child and Adult Care Food Program EXCEL FILE
Education Application and Management Plan for Centers
CACFP Fiscal Year 2018
Important: Read the instructions before completing this form. The terms used, such as “sponsoring organization”, “affiliated
centers,” “unaffiliated centers,” “principal,” “publicly funded,” “National Disqualified List,” and “business related offense,” are defined
in the “Terms and Definitions” section of the instructions.
PLEASE READ: This application was meant to be used in an Excel. Use the pdf application if completing with paper and pen. This file may not
display or print properly in all Excel versions and on all computers. If that is the case, please compete the pdf application. Maricopa
IMPORTANT: This file will not work properly with "Works", "OpenOffice", or ANY OTHER software besides Microsoft Excel.
Section I. Sponsoring Organization Information County
1. A. Provide the following organizational information:
Name of Organization Today's Date (mm/dd/yyyy) CTD No. DUNS No.
Human
Maricopa County Human Services Head Start 09/15/2017 072631 050391270
Mailing Address (Street or P.O. Box, City, State, ZIP) (Number of months remaining in this CACFP fiscal year...)
2150 S. Country Club Dr. Mesa AZ 85210 Consider basing your budget on 12 months.
Physical Address (if different) 10/1/2018 less 09/15/2017 13 Services
Contact Person E-Mail Address Telephone No. Fax No. Head
Maureen Mason masonm002@mail.maricopa.gov 480-540-2068 480-655-1154
Type of Organization: Start
Public Entity  City County Military Other (specify):
Private Entity  For-Profit Organization Nonprofit, Tax-Exempt (Attach a copy of your IRS letter of determination of tax-exempt status.)
Maureen
B. Enter the number of centers and enrollment count for each center under your administration that provides meal service:
Child Centers Adult Centers Emergency Shelters At-Risk Centers Head Start (or Outside School Hrs) Center
Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- Number of Nonprofit Tax- Mason
Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers:
20
Number of For-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers: Number of For-Profit Centers:
Number of child participants Number participants that receive Number of participants: Number of participants: Total number participating (all
in each eligibility category: Title XIX and/or Title XX benefits: (all in free category): (all in free category): participants are in the free category):
Title XIX and/or Title XX:
Free Free Free Free Free 516
Reduced Reduced Attach F/R documentation to
Paid Paid support site eligibility FY2018
C. List each of your claimable meal times: Attach additional pages as needed. (format like 11:00 [insert a space] AM)
Meal Type: Breakfast: AM Snack: Lunch: PM Snack: Supper: Evening Snack At-risk Supper At-risk Snack
Begin Claim: see
End Claim: attached
#VALUE! #VALUE!
D. Is your center open for weekend care?................................................ Saturday Sunday Not open on weekends
System
2. A. List all publicly funded programs in which you, your organization,
and its principals have participated during the past 7 years (attach additional pages as needed):
Date:
Name of Publicly Funded Program Contact Person Telephone Number
Office of Head Start Virginia Sturgill 602-506-8920
1/19/2018
B. Have you, your organization, or any principals identified with your organization ever been 2B.
been disqualified from participation in any publicly funded program(s) for violating that Yes No
programs requirements during the past 7 years?
Note: If your organization is a “public entity,” limit your response to those individuals who are directly involved in the
operations of the CACFP and to their immediate supervisors (responsible principles).
2C.
C. If “Yes,” were violations corrected and eligibility restored to participate in the program(s)?
If “No,” please attach explanation. Yes No N/A
3. Has any principal in your organization ever been convicted of any criminal business-related 3.
offense during the past 7 years? If "Yes", attach a detailed explanation Yes No N/A

----------------------------------------------------------------------- (PAGE 2 of 12) BELOW ----------------------------------------------------------------------
Section I. Sponsoring Organization Information (continued)
4. Has any person in your organization who is engaged in any activity related to the administration of the 4.
CACFP ever been convicted of a felony? …………………………………………………………………… Yes No
If "Yes," provide a detailed explanation:
5. Does your organization now participate or has your organization ever participated in program(s) 5.
Yes No
other than the CACFP that are funded through the United States Department of Agriculture (USDA)
(i.e. National School Lunch Program, Summer Food Service Program)? ………………………… Maricopa
6. Does your organization operate the CACFP in any other state(s)? If "Yes," please list below: 6.
Yes No
County
Section II. Management Plan
1. Program Requirement - Disbursement: If you operate multiple centers you must disburse CACFP reimbursements within Human
within five working days of receipt from ADE to centers under your administration. Indicate your system for disbursing payments:
1. Disbursement options
N/A (operate single (1) center) N/A (centers are part of the same legal entity and the organization maintains a central bank account) Services
Checks are hand delivered to centers Checks are mailed to centers Centers pick up checks Other (attach an explanation)
Head
2. A. Program Requirement - Staffing: Do you have written job descriptions that assign CACFP 2A. Start
Yes No
responsibilities and duties? ………………………………………………………………………………
B. Organizations operating the CACFP must have qualified staff to ensure effective program operation. Complete
the chart below to describe the qualifications you require for the person(s) that perform each listed function Maureen
(attach additional pages as needed):
Administrative [Note: One or more of the qualifications that you typed may be cut off, please be sure all text is visable.] Mason
Qualifications (What you look for when hiring for that position)
Responsible Position
Staff Function (Example: Director must have bachelor's degree, 10 years of day care experience, CPR
(i.e. director, cook, teacher)
certified, Certified Food Safety Manager, fingerprint clearance card, etc.)
Direct and Manage the CACFP Nutritionist Registered Dietitian, Masters Degree, CPR certified, Certified Food Safety Manager, fingerprint clearanc
Train staff Nutritionist Registered Dietitian, Masters Degree, CPR certified, Certified Food Safety Manager, fingerprint clearanc
Menu planning Catering Companies and Nutrition Registered Dietitian, Masters Degree, CPR certified, Certified Food Safety Manager, fingerprint clearanc
Purchasing N/A
Maintain records Nutritionist/Area Supervisor Registered Dietitian, Masters Degree, CPR certified, Certified Food Safety Manager, fingerprint clearanc
Enforce civil rights compliance Nutritionist/Area Supervisor Registered Dietitian, Masters Degree, CPR certified, Certified Food Safety Manager, fingerprint clearanc FY2018
Conduct self monitoring Nutritionist/Area Supervisor Registered Dietitian, Masters Degree, CPR certified, Certified Food Safety Manager, fingerprint clearanc
Prepare and submit claims Nutritionist Registered Dietitian, Masters Degree, CPR certified, Certified Food Safety Manager, fingerprint clearanc
Ensure accountability of funds Grants Accountant Bachelors Degree
Operational
Qualifications (What you look for when hiring for that position)
Responsible Position
Staff Function (Example: Director must have bachelor's degree, 10 years of day care experience, CPR certified,
(i.e. director, cook, teacher) System
Certified Food Safety Manager, fingerprint clearance card, etc.)
Prepare meals Catering Companies Maintain all appropriate inspection reports, fingerprint clearance card, Serv Safe certified
Date:
Serve meals Site Supervisor, Teacher, Teachin Bachelors Degree and/or CDA, CPR certified, food handlers card, fingerprint clearance card
Sanitation/cleaning Site Supervisor, Teacher, Teachin Bachelors Degree and/or CDA, CPR certified, food handlers card, fingerprint clearance card
Monitor participants Site Supervisor, Teacher, Teachin Bachelors Degree and/or CDA, CPR certified, food handlers card, fingerprint clearance card 1/19/2018
Take meal counts Site Supervisor, Teacher, Teachin Bachelors Degree and/or CDA, CPR certified, food handlers card, fingerprint clearance card
Maintain records Site Supervisor Bachelors Degree, CPR certified, food handlers card, fingerprint clearance card
3. Program Requirement - Meal Production Records: Organizations must document the menu, a specific listing of foods and
quantities used to prepare the meal and the planned number of servings. Indicate the method you will use to meet this
requirement: (Centers that exhibit successful meal production may have this requirement waived after a successful review.)
3.
The cook will complete Daily Meal Production Records on a daily basis. The center director (or another designated staff person)
will review the form to ensure the form is completed correctly.
Other (Attach a detailed plan as to your organization will conduct CACFP meal production records.)
If waived, provide date (obtained from past review documentation):

----------------------------------------------------------------------- (PAGE 3 of 12) BELOW ----------------------------------------------------------------------
Section II. Management Plan (continued)
4.
Program Requirement – Attendance and Meal Counts: Organizations must maintain records of daily attendance and a daily
count of the number of meals served to program participants, program staff, and non-program meals. Meal counts must be taken
at the "point of service." The "point of service" is that point in the meal service when you have observed that a creditable meal
was served to an eligible participant. Only the meals served to program participants are eligible for reimbursement. Check the
Maricopa
following appropriate items to indicate your method for meeting these requirements:
A. Attendance and Count of Meals Served to Participants:
4A. County
A designated staff person will document on the Point of Service Meal Count Sheets (Centers and Emergency Shelters), when
the person observes that a participant has been served a creditable meal. The count will be taken by participant name and by
meal type (breakfast, lunch, supper, or snack). The center director (or other designated staff person) will review the form to Human
ensure it is completed correctly.
Other (Specify):
Services
B. Count of Meals Served to Program Staff and Non-Program Persons:
4B.
Head
No meals are served to Program Staff and Non-Program Persons.
A designated staff person supervising the meal service will complete the Point of Service Meal Count Sheets (Centers and Start
Emergency Shelters), to record the number of meals served to program staff and the number of meals served to non-program
persons when the staff person has observed that a meal has been served. The center director will review the form to ensure
the form is completed correctly. Meals served to program staff and non-program persons are not reimbursable under the
CACFP. Maureen
Other (Specify):
Mason
5. Program Requirement - Training:
A. New staff must receive required CACFP training before they assume responsibility for program functions.
Indicate the method you will use to meet this requirement:
5A.
I will develop a training package based on the CACFP Business, Nutrition and Computer Track Training and other available
program resources. New staff will complete the training before assuming responsibility for program functions. Documentation of
the training will be maintained.
Other (Specify):
B. All CACFP organizations must provide annual training for all staff involved with operating the Food Program. This training must
FY2018
include topics specific to the CACFP such as meal components, portion size, meal count procedures, eligibility determination, record
keeping, and civil rights and the training must be documented with staff sign in sheets, agenda, and any materials provided for use
during the training. Please provide a date as to when your organization anticipates holding the training.
Complete the chart below to describe the planned training (attach additional pages as needed):
Proposed Date (must fall within
Required Topics
correct fiscal year)
Meal Pattern, Meal Count Procedures, Record Keeping, Claims Submission, Civil Rights, and System
8/1/2018
Reimbursement System (if applicable)
Other Topics (please list):
Date:
6. Program Requirement - Monitoring: Organizations with multiples sites and persons that own multiple independent
centers must use the Monitor Evaluation Form to monitor each site or independent center a minimum of three times per 1/19/2018
fiscal year with no more than six months between visits.
A. Complete the following chart to describe your monitoring plans (attach additional pages as needed):
Single Single site site – – not not applicable. applicable.
Name of Center (F) (R) (P) F/R Proposed Monitoring Dates (Month/Year)
Percent Visit 1 Visit 2 Visit 3
see attached monitoring plan #DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

----------------------------------------------------------------------- (PAGE 4 of 12) BELOW ----------------------------------------------------------------------
Section II. Management Plan (continued)
6. Program Requirement – Monitoring (continued)
B. You must demonstrate that you have an adequate number of staff to conduct required monitoring. 6B.
Do you sponsor 25 or more facilities? …………………………………………………… Yes No
If “Yes, submit a monitoring policy addressing number of FTE’s assigned with monitoring duties, areas covered
and addressing how organizations maintain regulatory monitoring compliance.
7. Program Requirement – Program Document Retention: You must maintain all current fiscal year program documents
on site or at the identified main business office. Current fiscal year documents may not be stored in any location that is Maricopa
not accessible to center personnel (i.e. at the residential office of the center owner). The documents must be made
available to ADE CACFP reviewers immediately upon request.
A. Current fiscal year CACFP documents are located: County
On site:
Main business address at: 2150 S. Country Club Dr. Mesa AZ 85210 Human
B. In addition, all CACFP records must be retained for a period of five years. These records are stored at:
234 N. Central, Phoenix AZ
Services
8. Program Requirement – Disclosure: Organizations applying to participate in the CACFP are required to disclose and
identify related-party transactions, less-than-arms-length transactions, and ownership interests in equipment, supplies,
vehicles, and facilities, or disclose any other information that inhibits ADE from making an informed assessment of the Head
allowability of a particular cost. 8.
Do you have any expenses that require disclosure?.......................................................................... Yes No Start
If "Yes", attach a detailed explanation.
9. Program Requirement – Subcontracts: Organizations may subcontract certain program functions. If you subcontract,
you must keep records to demonstrate compliance with procurement requirements and you must submit a copy of each Maureen
subcontract.
Important Note: You may not subcontract CACFP management functions, such as the preparation of application
Mason
materials, monitoring, claim preparation, or corrective action processes.
Check the functions you plan to subcontract:
N/A (No CACFP function will be subcontracted.) Food Service Data Processing Bookkeeping
Auditing - Name of auditor:
Other (Explain):
10. Program Requirement – Responsible Principals: All contracting organizations must provide information for at least two
persons responsible for the overall operation (attach additional pages as needed). Mailing address cannot be the business.
Position Name Non-Business Mailing Address Date of Birth
Owner N/A
Executive Director Bruce Liggott 1967 E. Chilton Dr. Tempe AZ 85283 9/30/1951
Chairman of the Board Alecia Jackson 3681 S. Buckaroo Tr. Gilbert AZ 85297 3/20/1965
Other (specify) Nutritionist Maureen Mason 2066 E. La Salle Way Gilbert AZ 85234 11/13/1978 FY2018
11. Provide the following documents. Please indicate that you have attached the required information by checking
each box below (as applicable):
REQUIRED TO BE PROVIDED WITH THIS APPLICATION:
Organizational Chart (chain of command) is included with this application [required]
Last three months of bank statements are included with this application [required]
CACFP RENEWAL certificate is included with this application. If new, provide Business, Nutrition, and Computer certificates [required]
Copy of outside employment policy (see draft attached to instructions) is included with this application [required]
Copy of DHS or other current license for each center [required]
System
Copy of training materials for current year. This includes; agendas, sign in sheet and presentation materials [required]
Copy of written notification provided to centers indicating unannounced reviews will be conducted [sponsors of multiple sites only]
Date:
NEXT 6 ITEMS MAY BE REQUIRED UNDER THE FOLLOWING CONDITIONS (indicate checkboxes if included with this application):
IF your organization subcontracts with another business entity for any aspect of food service, provide a copy to ADE (see No. 9 above).
IF your organization is a NON- PROFIT, PROVIDE proof of tax exemption for nonprofit organizations. 1/19/2018
IF your organization is a NON- PROFIT, list each member of the Board of Directors with address.
IF you have an "At-Risk After School Snack/Meal Program", PROVIDE facility area eligibility/enrichment activities.
IF you are a Sponsoring Organization with 25 or more facilities, SEND a copy of the policy addressing monitoring FTE’s.
IF you checked "Yes" to number 8 (above) , provide an explanation of any expenses that require disclosure.

----------------------------------------------------------------------- (PAGE 5 of 12) BELOW ----------------------------------------------------------------------
Section III. Budget
1. A. Administrative Labor
Nonprofit Food Service Administrative – Labor Justification — This section is used to provide detailed information for each
administrative position that has nonprofit food service responsibilities and is paid from the nonprofit food service account.
2. A. Administrative Benefits
Maricopa
Nonprofit Food Service Administrative – Budget Benefits — See separate instructions, Section III, Budget-H.
Administrative labor includes planning, organizing and managing the nonprofit food service. Labor costs include base salary, County
employment taxes, fringe benefits, overtime pay, holiday pay, compensatory leave, incentive payments and severance pay.
(Attach additional pages as needed.) [calculated] [calculated]
A. B. C. D. E. F. G. H. Human
Position (owner, director, monitor, Number of Hours per day Salary/Wage Annual Gross
clerk, trainer, etc.) Staff in for CACFP Salary/Wage per day Number of CACFP Pay CACFP portion of Services
Position duties only per hour (B x C x D) work days (E x F) benefits (see
AND instructions Section
CACFP Duties (planning, eligibility (For information only: if open weekdays, less bank holidays (8)= 252 days.) III, Budget – H) Head
determination, enrollment, etc.) (If open weekdays + 1 weekend day per week, less holidays (8)= 304 days.)
Position: Start
Nutritionist
CACFP Duties:
Monitoring, submit monthly claims, menu 1 X 2 X $30.00 = = = = = $60.00 X 252 $15,120.00 Maureen
Mason
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
FY2018
X X = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = X
System
Date:
Position:
CACFP Duties: (list position to calculate labor cost) 1/19/2018
X X = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = X
Administrative Cost - Labor: $15,120 $0
(1A) (2A)

----------------------------------------------------------------------- (PAGE 6 of 12) BELOW ----------------------------------------------------------------------
Section III. Budget (continued)
1. B. Operational Labor
Nonprofit Food Service Operational – Labor Justification — This section is used to provide detailed information for each
operational position that has nonprofit food service responsibilities and is paid from the nonprofit food service account.
2. B. Operational Benefits
Nonprofit Food Service Operational – Budget Benefits — See separate instructions, Section III, Budget-H. Maricopa
Operational labor includes the preparation and service of meals to participants. Labor costs include base salary,
County
employment taxes, fringe benefits, overtime pay, holiday pay, compensatory leave, incentive payments and severance pay.
(Attach additional pages as needed.)
A. B. C. D. E. F. G. H. Human
Position (Cook and teacher) Salary/Wage Gross
Number of Hours per day per day Annual CACFP Pay CACFP portion of
AND Staff in for CACFP Salary/Wage (B x C x D) Number of (E x F) benefits (see Services
per hour [all numbers [all numbers instructions Section
Position duties only work days
CACFP Duties (preparing and serving calculated in this calculated in this III, Budget – H)*
column] column] Head
meals, completing point of service, etc.)
Position:
Start
CACFP Duties: (list position to calculate labor cost)
X X = = X
Maureen
Mason
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
FY2018
X X = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = X
System
Position:
Date:
CACFP Duties: (list position to calculate labor cost)
X X = = = X 1/19/2018
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = X
Operational Cost - Labor: $0 $0
* Paid Vacation, Military Leave, Sick Leave, Health & Retirements Benefits, Disability, and Life Insurance (1B) (2B)

----------------------------------------------------------------------- (PAGE 7 of 12) BELOW ----------------------------------------------------------------------
Section III. Budget (continued)
Program Requirement: The organization must specifically identify each cost item in the budget and, where necessary, explain how each cost was
calculated. Include only those expenses paid from the nonprofit food service account.
(Attach additional pages as needed.) Maricopa
J.
Annual Cost For
Budget Line Item
Nonprofit Food Service County
OPERATIONAL
3.
Food — Include only the NET cost of food used (and the net cost of delivered meals), not the cost of all food purchased. Human
You must explain how you determined your cost figure.
Food costs were determined by:
Services
Total dollar amount for invoices from food service vendors, decrease in
number of sites and percent increase of food cost
$638,000.00
Head
N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.)
(field calculated below) Start
Food Costs for: Maricopa County Human Services Head Start: 3B. $638,000
4.
Supplies and Equipment — This category includes nonfood consumables and cleaning products.
Maureen
You must explain how you determined your cost figure.
Kitchen Cleaning Supplies: (Note: For consistency, base cost on 12 months.)
Mason
Paper goods (non-food consumables): (Note: For consistency, base cost on 12 months.)
N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.)
(field calculated below)
Supplies and Equipment Costs for: Maricopa County Human Services Head Start: 4B. $0 FY2018
Commodity Supplemental Food Program (CSFP)
The United States Deparment of Agriculture (USDA) offers commodity foods to participating CACFP sponsors. The State
of Arizona has opted out of this program in exchange for offering cash in lieu.
Indicate that you have read the above statement regarding commodities by checking this box
System
Date:
1/19/2018

----------------------------------------------------------------------- (PAGE 8 of 12) BELOW ----------------------------------------------------------------------
Section III. Budget - ADMINISTRATIVE Facility Costs
For this worksheet, you will need the following facility square footage calculations: Food Service Area, Office Area, Total Facility
Take the determined square footage of the CACFP office space and divide it by the square footage of the total facility.
Example: 150 ÷ 2,500 = 0.06 or 6% Maricopa
Square footage of CACFP (office space) area ÷ Square footage of the total facility = percentage of expenses attributable
to CACFP **required-please complete this sq. ft. equation
(Admin Sq. Ft.) (Total Sq. Ft.) County
Administrative (office space) ÷ = % (percentage rounded up)
(calculated) Human
Itemized Facility Costs
You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service ADMINISTRATIVE
K. L. M. N. Services
Itemized Service (calculated fields) (calculated fields) (calculated fields)
Is the facility owned, owned and fully depreciated, or lease/rented? Total Annual Percentage of Total Head
Owned Owned and fully depreciated Lease Space/Rented billed amount expenses (L x M)
attributed to CACFP
Start
5. Depreciation or Rent: [Should use 12 months for consistency.] [ERROR], COMPLETE ADMIN SQ. FT. ABOVE TO CALCULATE
X = %
(monthly rate) (# months) (calculated) (5A)
6. Contracted Services: Specify each item. Maureen
Contractor (from page 4, question 9)
X Mason
(contractor/description) (monthly cost) (# months)
X
(contractor/description) (monthly cost) (# months) %
X
(contractor/description) (monthly cost) (# months)
X
(contractor/description) (monthly cost) (# months)
(6A)
7. Communications: Specify each item. FY2018
X
(description - phone service) (monthly cost) (# months)
X
(description - internet service) (monthly cost) (# months)
X
%
(add ADMIN communication) (monthly cost) (# months)
X
System
(add ADMIN communication) (monthly cost) (# months)
X
Date:
(add ADMIN communication) (monthly cost) (# months)
X
(add ADMIN communication) (monthly cost) (# months) (7A) 1/19/2018
8. Other Costs: Specify each item.
X
(add ADMIN cost) (monthly cost) (# months)
X %
(add ADMIN cost) (monthly cost) (# months)
X
(add ADMIN cost) (monthly cost) (# months)
(8A)
N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.)

----------------------------------------------------------------------- (PAGE 9 of 12) BELOW ----------------------------------------------------------------------
Section III. Budget - OPERATIONAL Facility Costs
For this worksheet, you will need the following facility square footage calculations: Food Service Area, Office Area, Total Facility
Take the determined square footage of the CACFP food service and divide it by the square footage of the total facility.
Example: 525 ÷ 2,500 = 0.21 or 21%
Maricopa
Square footage of CACFP (food service) area ÷ Square footage of the total facility = percentage of expenses attributable
to CACFP
( Operational (locked because County
Operational (Food Service) ÷ = % (percentage rounded up)
Sq. Ft. here) already provided) (calculated)
Itemized Facility Costs Human
You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service OPERATIONAL
K. L. M. N.
Services
(calculated fields) (calculated fields) (calculated fields)
Itemized Service Total Annual Percentage of Total
billed amount expenses (L x M) Head
attributed to CACFP
5. Depreciation or Rent: [Should use 12 months for consistency.] [ERROR], COMPLETE ADMIN SQ. FT. ON PAGE 8 Start
X = Sq. Ft.? Sq. Ft.? %
(monthly rate) (# months) (calculated) (5B)
6. Contracted Services: Specify each item. Maureen
Contractor (from page 4, question 9)
X
(contractor/description) (monthly cost) (# months) Mason
X
(contractor/description) (monthly cost) (# months) %
X
(contractor/description) (monthly cost) (# months)
X
(contractor/description) (monthly cost) (# months)
(6B)
7. Utilities: Specify each item.
FY2018
X
(description - electric/gas) (monthly cost) (# months)
X
(description - water) (monthly cost) (# months)
X
%
(description - waste) (monthly cost) (# months)
System
X
(other utility) (monthly cost) (# months)
Date:
X
(other utility) (monthly cost) (# months)
X 1/19/2018
(other utility) (monthly cost) (# months) (7B)
8. Other Costs: Specify each item.
X
(add OPERATIONAL cost) (monthly cost) (# months)
X %
(add OPERATIONAL cost) (monthly cost) (# months)
X
(add OPERATIONAL cost) (monthly cost) (# months)
(8B)
N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.)

---------------------------------------------------------------------- (PAGE 10 of 12) BELOW ---------------------------------------------------------------------
9. Costs for Unaffiliated Centers - Sponsoring Organizations
N/A - All centers are affiliated
Sponsors of unaffiliated centers must ensure that each center maintains a nonprofit food service. The information for this section is obtained
from the individual budget pages for each center.
Sponsors may use up to 15% of the projected annual CACFP reimbursement to pay for actual allowable administrative costs incurred in the Maricopa
operation of the nonprofit food service. These amounts are calculated into the budget during the application approval process.
Enter the projected CACFP reimbursements and costs for each unaffiliated center. (attach additional pages as needed):
County
R. S.
Annual Cost For
Human
Name of Center - Indicate how you determine administrative and Nonprofit Food Service Nonprofit Food Service
operational costs ADMINISTRATIVE OPERATIONAL
Services
Head
Start
Total Unaffiliated Center Costs 9A. $0.00 9B. $0.00
Maureen
Section III. Budget (continued)
Mason
FY2018 BUDGET
10. A. Projected Annual CACFP Administrative Expenses
Administrative Costs (rounded)
1.A. Administrative Cost - Labor: 1.A. $15,120.00
2.A. Administrative Cost - Benefits: 2.A. $0.00
FY2018
5.A. Administrative Cost - Depreciation or Rent: 5.A. $0.00
6.A. Administrative Cost - Contracted Services: 6.A. $0.00
7.A. Administrative Cost - Communications: 7.A. $0.00
8.A. Administrative Cost - Other Costs: 8.A. $0.00
9.A. Administrative Cost - Unaffiliated Costs: 9.A. $0.00
Total CACFP Administrative Expenses: 10.A. $15,120.00
System
10. B. Projected Annual CACFP Operational Expenses
Date:
Operational Costs (rounded)
1.B. Operating Cost - Labor: 1.B. $0.00
2.B. Operating Cost - Benefits: 2.B. $0.00 1/19/2018
3.B. Operating Cost - Food: 3.B. $638,000.00
4.B. Operating Cost - Supplies: 4.B. $0.00
5.B. Operating Cost - Depreciation or Rent: 5.B. $0.00
6.B. Operating Cost - Contracted Services: 6.B. $0.00
7.B. Operating Cost - Utilities: 7.B. $0.00
8.B. Operating Cost - Other Costs: 8.B. $0.00
9.B. Operating Cost - Unaffiliated Costs: 9.B. $0.00
Total CACFP Operational Expenses: 10.B. $638,000.00

---------------------------------------------------------------------- (PAGE 11 of 12) BELOW ---------------------------------------------------------------------
11. Projected Annual Non-CACFP Income Required for Nonprofit Food Service Costs
Program Requirement: Reimbursements under the CACFP subsidize the nonprofit food service operation but may not be sufficient to cover
all food service expenses. Any funds specifically designated as food service account funds are restricted and may not be used to fund any
other costs in your organization.
A. Total projected annual nonprofit food service costs
(add 10A + 10B above): Maricopa
11. A. $653,120.00
B. Projected annual CACFP reimbursement for the upcoming fiscal year
(based on previous FY reimbursement. New applicants see Reimbursement County
Projection Worksheet): 11. B. $440,000.00
C. Per the Code of Federal Regulations (CFR) 226.16(b)(1), administrative costs Human
charged to the program should not exceed 15% of projected annual CACFP
reimbursement (divide; 10A above ÷ 11B): 11. C. 3.44%
D. Other non-CACFP income to cover remaining food service costs (tuition, DES Services
subsidies, donations, etc.) (subtract; 11A - 11B). This income must be specifically
designated for use in food service: 11. D. $213,120.00 Head
E. Total projected funds required for the operation of a non-profit food service
(add; 11B + 11D which should be the same as 11A): Start
11. E. $653,120.00
Maureen
Mason
FY2018
System
Date:
1/19/2018

---------------------------------------------------------------------- (PAGE 12 of 12) BELOW ---------------------------------------------------------------------
Section IV. Certification
This is to certify that _____________________________________________ meets all of the requirements for Renewing
(Print Sponsoring Institution Name)
Institutions contained in 7 CFR 226.6(b)(2). This means ________________________________________ certifies that:
(Print Name of Signing Official)
• The management plan on file with the Arizona Department of Education is complete and up to date. Any necessary updates are
attached;
• No sponsored facility or principal of a sponsored facility is currently on the CACFP National Disqualified List;
• The outside employment policy most recently submitted to the Arizona Department of Education remains current and in effect;
• The names, mailing addresses, and dates of birth of all current institution principals have been submitted to the Arizona
Department of Education;
• The Institution itself, and the Institution’s principals, are not currently on the CACFP National Disqualified List; Maricopa
• The list of any publicly funded programs institution and principals have participated in the past seven years is current;
• The Institution itself, and the Institution’s principals, have not been determined ineligible for any other publicly funded programs
County
due to violation of the Program’s requirements in the past seven years;
• No principals of the Institution have been convicted of any activity that occurred during the past seven years and that indicated a
lack of business integrity; and Human
• The Institution is currently compliant with the required performance standards of financial viability and management, administrative
capability, and program accountability as described in 7 §CFR 226.6(b)(2)(vii).
• All staff have been trained according to the CACFP training requirements. Services
Any of the above information that has changed since the initial application has already been submitted to the Arizona Department of Head
Education or is being submitted with this certification.
Start
I certify that all of the above information is true and correct.
Maureen
Mason
Signature - Official of Organization Date Title
Printed Name of Signing Official
FOR ADE USE ONLY
Effective Date:
Signature - ADE Representative Date Title of the ADE Representative
1/19/2018
---------------------------------------------------------------------- END OF APPLICATION -----------------------------------------------------------------------
Beginning of fiscal yr: October 1, 2017 End of fiscal yr: September 30, 2018 updated 07/01/2017