MARICOPA COUNTY HEAD START CACFP APPLICATION.PDF

Arizona Department of Child and Adult Care Food Program EXCEL FILE
Education Management Plan for Centers
CACFP Fiscal Year 2017
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 and then scan it to
send by email.
IMPORTANT: This file will not work properly with "Works", "OpenOffice", or ANY OTHER software besides Microsoft Excel.
Section I. Sponsoring Organization Information
1. A. Provide the following organizational information:
Name of Organization Today's Date (mm/dd/yyyy) CTD No. DUNS No.
Maricopa County Human Services Head Start 09/25/2016 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) 10/1/2017 less 09/25/2016 13
Contact Person E-Mail Address Telephone No. Fax No.
Maureen Mason masonm002@mail.maricopa.gov 480-464-9669 480-655-1154
Type of Organization:
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.)
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-
Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers: Exempt Centers:
37
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 555
Reduced Reduced Attach F/R documentation to
Paid Paid support site eligibility
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
Claim attached
#VALUE! #VALUE!
D. Is your center open for weekend care?................................................ Saturday Sunday Not open on weekends
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):
Name of Publicly Funded Program Contact Person Telephone Number
Office of Head Start Leslie Ryan 480-464-9669
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).
C. If “Yes,” were violations corrected and eligibility restored to participate in the program(s)? 2C.
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
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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)? …………………………
6. Does your organization operate the CACFP in any other state(s)? If "Yes," please list below: 6.
Yes No
Section II. Management Plan
1. Program Requirement - Disbursement: If you operate multiple centers you must disburse CACFP reimbursements within
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)
Checks are hand delivered to centers Checks are mailed to centers Centers pick up checks Other (attach an explanation)
2. A. Program Requirement - Staffing: Do you have written job descriptions that assign CACFP 2A.
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
(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.
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 cleara
Train staff Nutritionist Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safety Manager, fingerprint cleara
Menu planning Nutritionist Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safety Manager, fingerprint cleara
Purchasing N/A
Maintain records Nutritionist/Area Supervisor Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safety Manager, fingerprint cleara
Enforce civil rights compliance Nutritionist/Area Supervisor Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safety Manager, fingerprint cleara
Conduct self monitoring Nutritionist/Area Supervisor Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safety Manager, fingerprint cleara
Prepare and submit claims Nutritionist Registered Dietitian, Masters Degree, CPR Certified, Certified Food Safety Manager, fingerprint cleara
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)
Certified Food Safety Manager, fingerprint clearance card, etc.)
Prepare meals School Districts/Catering Compan Maintain all appropriate insepction reports, fingerprint clearance card, Serv Safe certified
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
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 and/or CDA, 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):
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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 following appropriate items to indicate your method for meeting these requirements:
A. Attendance and Count of Meals Served to Participants:
4A. 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
ensure it is completed correctly.
Other (Specify):
B. Count of Meals Served to Program Staff and Non-Program Persons:
4B.
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
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.
Other (Specify):
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
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
Required Topics
within correct fiscal year)
Meal Pattern, Meal Count Procedures, Record Keeping, Claims Submission, Civil Rights, and
6/1/2017
Reimbursement System (if applicable)
Other Topics (please list): Empower Program [ERROR]
enter dates in current fiscal year
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
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!
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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
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:
On site:
Main business address at: 2150 S. Country Club Dr. Mesa AZ 85210
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
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
allowability of a particular cost. 8.
Do you have any expenses that require disclosure?.......................................................................... Yes No
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
subcontract.
Important Note: You may not subcontract CACFP management functions, such as the preparation of application
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 2 persons
responsible for the overall operation (attach additional pages as needed). Mailing address cannot be the business.
Name Non-Business Mailing Address Date of Birth
Owner N/A
Executive Director Bruce Liggott
Chairman of the Board Alecia Jackson
Other (specify) Nutritionist Maureen Mason
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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
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,
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.
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
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)
determination, enrollment, etc.) (If open weekdays + 1 weekend day per week, less holidays (8)= 304 days.)
Position:
Nutritionist
CACFP Duties:
Monitoring, submit monthly claims, menu 1 X 2 X $30.00 = = = = = $60.00 X 252 $15,120.00
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = = = = = = X
Administrative Cost - Labor: $15,120 $0
(1A) (2A)
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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.
Operational labor includes the preparation and service of meals to participants. Labor costs include base salary,
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.
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
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)*
meals, completing point of service, etc.) column] column]
Position:
Site Supervisor
CACFP Duties:
Point of service, claiming meals 1 X 1 X $15.00 = = $15.00 X 252 $3,780.00
appropriately, preparing food for family style
Position:
Teacher
CACFP Duties:
Point of service, preparing food for family 2 X 1 X $12.00 = = = = = = $24.00 X 252 $6,048.00
style
Position:
Teacher Assistant
CACFP Duties:
Point of service, preparing food for family 1 X 1 X $10.00 = = = = = = = = $10.00 X 252 $2,520.00
style
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = X
Position:
CACFP Duties: (list position to calculate labor cost)
X X = = = = = = = = X
Operational Cost - Labor: $12,348 $0
* Paid Vacation, Military Leave, Sick Leave, Health & Retirements Benefits, Disability, and Life Insurance (1B) (2B)
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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.)
J.
Annual Cost For
Budget Line Item
Nonprofit Food Service
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.
You must explain how you determined your cost figure.
Food costs were determined by:
Total dollar amount for invoices from food service vendors, decrease in
number of sites, and percent increase of food cost
$612,950.00
N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.)
(field calculated below)
Food Costs for: Maricopa County Human Services Head Start: 3B. $612,950
4.
Supplies and Equipment — This category includes nonfood consumables and cleaning products.
You must explain how you determined your cost figure.
Kitchen Cleaning Supplies: (Note: For consistency, base cost on 12 months.)
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
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
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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%
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.)
Administrative (office space) ÷ = % (percentage rounded up)
(calculated)
Itemized Facility Costs
You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service ADMINISTRATIVE
K. L. M. N.
Itemized Service (calculated fields) (calculated fields) (calculated fields)
Is the facility owned, owned and fully depreciated, or lease/rented? Total Annual Percentage of Total
billed amount expenses (L x M)
Owned Owned and fully depreciated Lease Space/Rented
attributed to CACFP
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.
Contractor (from page 4, question 9)
X
(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.
X
(description - phone service) (monthly cost) (# months)
X
(description - internet service) (monthly cost) (# months)
X
%
(add ADMIN communication) (monthly cost) (# months)
X
(add ADMIN communication) (monthly cost) (# months)
X
(add ADMIN communication) (monthly cost) (# months)
X
(add ADMIN communication) (monthly cost) (# months) (7A)
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)
(
N/A (Check this box only if no cost in this category is paid from the nonprofit food service account.)
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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%
Square footage of CACFP (food service) area ÷ Square footage of the total facility = percentage of expenses attributable
to CACFP
( Operational (locked because
Operational (Food Service) ÷ = % (percentage rounded up)
Sq. Ft. here) already provided) (calculated)
Itemized Facility Costs
You must explain how you determined your cost figures. Annual Cost For Nonprofit Food Service OPERATIONAL
K. L. M. N.
(calculated fields) (calculated fields) (calculated fields)
Itemized Service Total Annual Percentage of Total
billed amount expenses (L x M)
attributed to CACFP
5. Depreciation or Rent: [Should use 12 months for consistency.] [ERROR], COMPLETE ADMIN SQ. FT. ON PAGE 8
X = Sq. Ft.? Sq. Ft.? %
(monthly rate) (# months) (calculated) (5B)
6. Contracted Services: Specify each item.
Contractor (from page 4, question 9)
X
(contractor/description) (monthly cost) (# months)
X
(contractor/description) (monthly cost) (# months) %
X
(contractor/description) (monthly cost) (# months)
X
(contractor/description) (monthly cost) (# months)
(6B)
7. Utilities: Specify each item.
X
(description - electric/gas) (monthly cost) (# months)
X
(description - water) (monthly cost) (# months)
X
%
(description - waste) (monthly cost) (# months)
X
(other utility) (monthly cost) (# months)
X
(other utility) (monthly cost) (# months)
X
(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.)
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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 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):
R. S.
Annual Cost For
Name of Center - Indicate how you determine administrative and Nonprofit Food Service Nonprofit Food Service
operational costs ADMINISTRATIVE OPERATIONAL
Total Unaffiliated Center Costs 9A. $0.00 9B. $0.00
Section III. Budget (continued)
FY2017 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
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
10. B. Projected Annual CACFP Operational Expenses
Operational Costs (rounded)
1.B. Operating Cost - Labor: 1.B. $12,348.00
2.B. Operating Cost - Benefits: 2.B. $0.00
3.B. Operating Cost - Food: 3.B. $612,950.00
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. $625,298.00
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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):
11. A. $640,418.00
B. Projected annual CACFP reimbursement for the upcoming fiscal year
(based on previous FY reimbursement. New applicants see Reimbursement
Projection Worksheet): 11. B. $329,000.00
C. Per the Code of Federal Regulations (CFR) 226.16(b)(1), administrative costs
charged to the program should not exceed 15% of projected annual nonprofit
food service costs (divide; 10A above ÷ 11A): 11. C. 2.36%
D. Other non-CACFP income to cover remaining food service costs (tuition, DES
subsidies, donations, etc.) (subtract; 11A - 11B). This income must be
specifically designated for use in food service: 11. D. $311,418.00
E. Total projected funds required for the operation of a non-profit food service
(add; 11B + 11D which should be the same as 11A):
11. E. $640,418.00
Signature Requirement: An authorized representative of the organization must review this document
and electronically sign the Certifcation Statement located on the Renewal Application Checklist.prior to
application approval.
Notes:
--------------------------------------------------------------------- END OF APPLICATION ----------------------------------------------------------------------
Beginning of fiscal yr: October 1, 2016 End of fiscal yr: September 30, 2017 updated 06/09/2016 tn
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